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_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	4			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	4			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	4			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	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
H0028	014	0	1	01	01	H0028_014_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
H0028	014	0	1	01	01	H0028_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		95.00	35.00		35.00
H0028	014	0	1	01	01	H0028_014_0	4			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																								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		35.00
H0028	014	0	1	01	01	H0028_014_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
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		95.00	35.00		35.00
H0028	016	0	1	02	01	H0028_016_0	8			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																								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
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					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
H0028	017	0	1	01	01	H0028_017_0	4			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	4			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	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		95.00	35.00		35.00
H0028	017	0	1	01	01	H0028_017_0	4			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																								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
H0028	017	0	1	01	01	H0028_017_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
H0028	019	0	1	01	01	H0028_019_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
H0028	019	0	1	01	01	H0028_019_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
H0028	019	0	1	01	01	H0028_019_0	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		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		70.00	35.00		35.00
H0028	019	0	1	01	01	H0028_019_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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
H0028	019	0	1	01	01	H0028_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 Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0028	021	0	1	01	01	H0028_021_0	4			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
H0028	021	0	1	01	01	H0028_021_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
H0028	021	0	1	01	01	H0028_021_0	4			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		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		70.00	35.00		35.00
H0028	021	0	1	01	01	H0028_021_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H0028	021	0	1	01	01	H0028_021_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
H0028	023	0	1	01	01	H0028_023_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	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
H0028	023	0	1	01	01	H0028_023_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	7.00		21.00																									20.00		60.00				7.00		0.00				7.00				7.00		0.23				0.67	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00		21.00				20.00		60.00	7.00		0.00	7.00		7.00
H0028	023	0	1	01	01	H0028_023_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		70.00	35.00		35.00
H0028	023	0	1	01	01	H0028_023_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		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					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
H0028	024	0	1	01	01	H0028_024_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
H0028	024	0	1	01	01	H0028_024_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
H0028	024	0	1	01	01	H0028_024_0	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		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		70.00	35.00		35.00
H0028	024	0	1	01	01	H0028_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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
H0028	024	0	1	01	01	H0028_024_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
H0028	025	1	1	01	01	H0028_025_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
H0028	025	1	1	01	01	H0028_025_1	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
H0028	025	1	1	01	01	H0028_025_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		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		70.00	35.00		35.00
H0028	025	1	1	01	01	H0028_025_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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
H0028	025	1	1	01	01	H0028_025_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
H0028	025	2	1	01	01	H0028_025_2	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
H0028	025	2	1	01	01	H0028_025_2	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
H0028	025	2	1	01	01	H0028_025_2	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		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		70.00	35.00		35.00
H0028	025	2	1	01	01	H0028_025_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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
H0028	025	2	1	01	01	H0028_025_2	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
H0028	027	0	1	01	01	H0028_027_0	4			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
H0028	027	0	1	01	01	H0028_027_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
H0028	027	0	1	01	01	H0028_027_0	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		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		70.00	35.00		35.00
H0028	027	0	1	01	01	H0028_027_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H0028	027	0	1	01	01	H0028_027_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
H0028	028	0	1	01	01	H0028_028_0	4			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
H0028	028	0	1	01	01	H0028_028_0	4			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
H0028	028	0	1	01	01	H0028_028_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		70.00	35.00		35.00
H0028	028	0	1	01	01	H0028_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H0028	028	0	1	01	01	H0028_028_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
H0028	029	0	1	01	01	H0028_029_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
H0028	029	0	1	01	01	H0028_029_0	4			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	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	029	0	1	01	01	H0028_029_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	35		35																								50		50				35		35			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
H0028	029	0	1	01	01	H0028_029_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
H0028	030	0	1	01	01	H0028_030_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
H0028	030	0	1	01	01	H0028_030_0	4			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	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	030	0	1	01	01	H0028_030_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	35		35																								48		48				35		35			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
H0028	030	0	1	01	01	H0028_030_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
H0028	031	0	1	01	01	H0028_031_0	5		N	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	031	0	1	01	01	H0028_031_0	5		N	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	031	0	1	01	01	H0028_031_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	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
H0028	031	0	1	01	01	H0028_031_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	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
H0028	031	0	1	01	01	H0028_031_0	5		N	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
H0028	034	0	1	01	01	H0028_034_0	5		N	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	034	0	1	01	01	H0028_034_0	5		N	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	034	0	1	01	01	H0028_034_0	5		N	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		70.00	35.00		35.00
H0028	034	0	1	01	01	H0028_034_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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
H0028	034	0	1	01	01	H0028_034_0	5		N	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
H0028	035	0	1	01	01	H0028_035_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	035	0	1	01	01	H0028_035_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	035	0	1	01	01	H0028_035_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	035	0	1	01	01	H0028_035_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				90.00	35		35																								39		39				35		35			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
H0028	035	0	1	01	01	H0028_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
H0028	036	0	1	01	01	H0028_036_0	4		N	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	036	0	1	01	01	H0028_036_0	4		N	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	036	0	1	01	01	H0028_036_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	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
H0028	036	0	1	01	01	H0028_036_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	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
H0028	036	0	1	01	01	H0028_036_0	4		N	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
H0028	037	0	1	01	01	H0028_037_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	037	0	1	01	01	H0028_037_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	037	0	1	01	01	H0028_037_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	037	0	1	01	01	H0028_037_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	35		35																								45		45				35		35			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
H0028	037	0	1	01	01	H0028_037_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
H0028	039	0	1	01	01	H0028_039_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
H0028	039	0	1	01	01	H0028_039_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, Select Care Drugs										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	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H0028	039	0	1	01	01	H0028_039_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	35		35																								45		45				35		35			35			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
H0028	039	0	1	01	01	H0028_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	039	0	1	01	01	H0028_039_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				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	041	0	1	01	01	H0028_041_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	041	0	1	01	01	H0028_041_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	041	0	1	01	01	H0028_041_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		95.00	35.00		35.00
H0028	041	0	1	01	01	H0028_041_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H0028	041	0	1	01	01	H0028_041_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
H0028	042	0	1	01	01	H0028_042_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
H0028	042	0	1	01	01	H0028_042_0	4			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
H0028	042	0	1	01	01	H0028_042_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		95.00	35.00		35.00
H0028	042	0	1	01	01	H0028_042_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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
H0028	042	0	1	01	01	H0028_042_0	4			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	043	1	1	01	01	H0028_043_1	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
H0028	043	1	1	01	01	H0028_043_1	4			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	043	1	1	01	01	H0028_043_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		95.00	35.00		35.00
H0028	043	1	1	01	01	H0028_043_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H0028	043	1	1	01	01	H0028_043_1	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
H0028	043	2	1	01	01	H0028_043_2	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	043	2	1	01	01	H0028_043_2	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	043	2	1	01	01	H0028_043_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		95.00	35.00		35.00
H0028	043	2	1	01	01	H0028_043_2	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H0028	043	2	1	01	01	H0028_043_2	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
H0028	044	0	1	01	01	H0028_044_0	5		N	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	044	0	1	01	01	H0028_044_0	5		N	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	044	0	1	01	01	H0028_044_0	5		N	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		70.00	35.00		35.00
H0028	044	0	1	01	01	H0028_044_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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
H0028	044	0	1	01	01	H0028_044_0	5		N	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
H0028	045	0	1	01	01	H0028_045_0	5		N	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	045	0	1	01	01	H0028_045_0	5		N	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	045	0	1	01	01	H0028_045_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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
H0028	045	0	1	01	01	H0028_045_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				71.00	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
H0028	045	0	1	01	01	H0028_045_0	5		N	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
H0028	046	0	1	01	01	H0028_046_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	046	0	1	01	01	H0028_046_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	046	0	1	01	01	H0028_046_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	046	0	1	01	01	H0028_046_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		70.00	35.00		35.00
H0028	046	0	1	01	01	H0028_046_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	047	0	1	01	01	H0028_047_0	3			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
H0028	047	0	1	01	01	H0028_047_0	3			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
H0028	047	0	1	01	01	H0028_047_0	3			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		70.00	35.00		35.00
H0028	047	0	1	01	01	H0028_047_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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
H0028	047	0	1	01	01	H0028_047_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										35.00						35.00			35.00			35.00		35.00
H0028	048	1	1	01	01	H0028_048_1	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
H0028	048	1	1	01	01	H0028_048_1	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
H0028	048	1	1	01	01	H0028_048_1	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	048	1	1	01	01	H0028_048_1	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	28		28																								28		28				28		28			28			28								Preferred Generic, 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	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	048	2	1	01	01	H0028_048_2	9			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	9			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	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	048	2	1	01	01	H0028_048_2	9			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	28		28																								28		28				28		28			28			28								Preferred Generic, 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	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
H0028	051	0	1	01	01	H0028_051_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
H0028	051	0	1	01	01	H0028_051_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	051	0	1	01	01	H0028_051_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H0028	051	0	1	01	01	H0028_051_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	40		40																								40		40				40		40			40			40								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	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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	051	0	1	01	01	H0028_051_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
H0028	053	1	1	01	01	H0028_053_1	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
H0028	053	1	1	01	01	H0028_053_1	4			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	053	1	1	01	01	H0028_053_1	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		95.00	35.00		35.00
H0028	053	1	1	01	01	H0028_053_1	4			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																								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
H0028	053	1	1	01	01	H0028_053_1	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
H0028	053	3	1	01	01	H0028_053_3	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
H0028	053	3	1	01	01	H0028_053_3	4			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	053	3	1	01	01	H0028_053_3	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		95.00	35.00		35.00
H0028	053	3	1	01	01	H0028_053_3	4			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																								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
H0028	053	3	1	01	01	H0028_053_3	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
H0028	054	1	1	02	01	H0028_054_1	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
H0028	054	1	1	02	01	H0028_054_1	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
H0028	054	1	1	02	01	H0028_054_1	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		95.00	35.00		35.00
H0028	054	1	1	02	01	H0028_054_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H0028	054	1	1	02	01	H0028_054_1	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
H0028	054	2	1	02	01	H0028_054_2	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
H0028	054	2	1	02	01	H0028_054_2	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
H0028	054	2	1	02	01	H0028_054_2	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		95.00	35.00		35.00
H0028	054	2	1	02	01	H0028_054_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H0028	054	2	1	02	01	H0028_054_2	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
H0028	055	0	1	02	01	H0028_055_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
H0028	055	0	1	02	01	H0028_055_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	055	0	1	02	01	H0028_055_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H0028	055	0	1	02	01	H0028_055_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	48		48																								48		48				48		48			48			48								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	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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	055	0	1	02	01	H0028_055_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
H0028	056	0	1	02	01	H0028_056_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
H0028	056	0	1	02	01	H0028_056_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	056	0	1	02	01	H0028_056_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H0028	056	0	1	02	01	H0028_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	40		40																								40		40				40		40			40			40								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	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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	056	0	1	02	01	H0028_056_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
H0028	059	0	1	01	01	H0028_059_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
H0028	059	0	1	01	01	H0028_059_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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
H0028	059	0	1	01	01	H0028_059_0	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		95.00	35.00		35.00
H0028	059	0	1	01	01	H0028_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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
H0028	059	0	1	01	01	H0028_059_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
H0028	060	0	1	01	01	H0028_060_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, Select Care Drugs										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	4			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, Select Care Drugs										8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H0028	060	0	1	01	01	H0028_060_0	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		115.00				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		85.00	35.00		35.00
H0028	060	0	1	01	01	H0028_060_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	40		40																								40		40				40		40			40			40								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	060	0	1	01	01	H0028_060_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	060	0	1	01	01	H0028_060_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				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	062	0	1	01	01	H0028_062_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
H0028	062	0	1	01	01	H0028_062_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
H0028	062	0	1	01	01	H0028_062_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		70.00	35.00		35.00
H0028	062	0	1	01	01	H0028_062_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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
H0028	062	0	1	01	01	H0028_062_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
H0028	063	0	1	01	01	H0028_063_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
H0028	063	0	1	01	01	H0028_063_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
H0028	063	0	1	01	01	H0028_063_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		70.00	35.00		35.00
H0028	063	0	1	01	01	H0028_063_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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		35.00
H0028	063	0	1	01	01	H0028_063_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
H0028	065	0	1	01	01	H0028_065_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
H0028	065	0	1	01	01	H0028_065_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
H0028	065	0	1	01	01	H0028_065_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		95.00	35.00		35.00
H0028	065	0	1	01	01	H0028_065_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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		35.00
H0028	065	0	1	01	01	H0028_065_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
H0028	066	0	1	02	01	H0028_066_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
H0028	066	0	1	02	01	H0028_066_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
H0028	066	0	1	02	01	H0028_066_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		95.00	35.00		35.00
H0028	066	0	1	02	01	H0028_066_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H0028	066	0	1	02	01	H0028_066_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
H0028	067	0	1	02	01	H0028_067_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	067	0	1	02	01	H0028_067_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	067	0	1	02	01	H0028_067_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H0028	067	0	1	02	01	H0028_067_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H0028	067	0	1	02	01	H0028_067_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	067	0	1	02	01	H0028_067_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
H0028	069	0	1	01	01	H0028_069_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
H0028	069	0	1	01	01	H0028_069_0	4			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	069	0	1	01	01	H0028_069_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	069	0	1	01	01	H0028_069_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	35		35																								40		40				35		35			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
H0028	069	0	1	01	01	H0028_069_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
H0028	070	0	1	01	01	H0028_070_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
H0028	070	0	1	01	01	H0028_070_0	4			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	070	0	1	01	01	H0028_070_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	070	0	1	01	01	H0028_070_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	35		35																								50		50				35		35			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
H0028	070	0	1	01	01	H0028_070_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
H0028	071	0	1	01	01	H0028_071_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	071	0	1	01	01	H0028_071_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	071	0	1	01	01	H0028_071_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0028	071	0	1	01	01	H0028_071_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	35		35																								50		50				35		35			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
H0028	071	0	1	01	01	H0028_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
H0028	072	0	1	01	01	H0028_072_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
H0028	072	0	1	01	01	H0028_072_0	4			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	072	0	1	01	01	H0028_072_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		95.00	35.00		35.00
H0028	072	0	1	01	01	H0028_072_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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		35.00
H0028	072	0	1	01	01	H0028_072_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
H0028	073	0	1	01	01	H0028_073_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
H0028	073	0	1	01	01	H0028_073_0	4			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
H0028	073	0	1	01	01	H0028_073_0	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		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		70.00	35.00		35.00
H0028	073	0	1	01	01	H0028_073_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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
H0028	073	0	1	01	01	H0028_073_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
H0028	074	1	1	01	01	H0028_074_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
H0028	074	1	1	01	01	H0028_074_1	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
H0028	074	1	1	01	01	H0028_074_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		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		70.00	35.00		35.00
H0028	074	1	1	01	01	H0028_074_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H0028	074	1	1	01	01	H0028_074_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
H0028	074	2	1	01	01	H0028_074_2	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
H0028	074	2	1	01	01	H0028_074_2	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
H0028	074	2	1	01	01	H0028_074_2	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		70.00	35.00		35.00
H0028	074	2	1	01	01	H0028_074_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H0028	074	2	1	01	01	H0028_074_2	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
H0028	075	0	1	01	01	H0028_075_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
H0028	075	0	1	01	01	H0028_075_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
H0028	075	0	1	01	01	H0028_075_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		70.00	35.00		35.00
H0028	075	0	1	01	01	H0028_075_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H0028	075	0	1	01	01	H0028_075_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
H0028	076	0	1	01	01	H0028_076_0	4			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				1.00	24		24																								24		24				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H0028	076	0	1	01	01	H0028_076_0	4			Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H0028	076	0	1	01	01	H0028_076_0	4			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	25		25																								25		25				25		25			25			25								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	076	0	1	01	01	H0028_076_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	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		35.00
H0028	076	0	1	01	01	H0028_076_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	076	0	1	01	01	H0028_076_0	4			Select Care Drugs	4	11	1	1	6	1	110		01		110	1	30		100				1	2				30		100	30		31				1.00	15		15																								15		15				15		0			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		105.00				35.00		105.00	0.00		0.00	35.00		35.00
H0028	077	0	1	01	01	H0028_077_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	077	0	1	01	01	H0028_077_0	4			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
H0028	077	0	1	01	01	H0028_077_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H0028	077	0	1	01	01	H0028_077_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H0028	077	0	1	01	01	H0028_077_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H0028	077	0	1	01	01	H0028_077_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				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
H0029	009	0	1	02	01	H0029_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0029	009	0	1	02	01	H0029_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0029	009	0	1	02	01	H0029_009_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											168.18	25	25	25				168.18	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
H0029	009	0	1	02	01	H0029_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											60.43	30	30	30				60.43	30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0029	009	0	1	02	01	H0029_009_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, Select Care Drugs																								
H0029	009	0	1	02	01	H0029_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																								
H0029	011	0	1	02	01	H0029_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0029	011	0	1	02	01	H0029_011_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0029	011	0	1	02	01	H0029_011_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.08	25	25	25				155.08	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
H0029	011	0	1	02	01	H0029_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											46.48	36	36	36				46.48	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
H0029	011	0	1	02	01	H0029_011_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, Select Care Drugs																								
H0029	011	0	1	02	01	H0029_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																								
H0074	001	0	1	04	01	H0074_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																								
H0074	001	0	1	04	01	H0074_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.01	25	25	25				159.01	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
H0074	001	0	1	04	01	H0074_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											62.83	36	36	36				62.83	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
H0074	001	0	1	04	01	H0074_001_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, Select Care Drugs																								
H0074	001	0	1	04	01	H0074_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																								
H0074	004	0	1	04	01	H0074_004_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								19.00	38.00	57.00					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0074	004	0	1	04	01	H0074_004_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0074	004	0	1	04	01	H0074_004_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											115.41	20	20	20				115.41	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
H0074	004	0	1	04	01	H0074_004_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											36.75	40	40	40				35.83	39	39	39										40	40	40				39	39	39			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
H0074	004	0	1	04	01	H0074_004_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, Select Care Drugs																								
H0074	004	0	1	04	01	H0074_004_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								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																								
H0104	012	0	1	04	01	H0104_012_0	3			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	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	3			Generic	4	01	1	2	2	1		110	01		110	1				30		100	1	2				30		100	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	3			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	2				30		100	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	3			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		100	1	2				30		100	30		31											98.58	43		43				85.05	38		38										43		43				38		38			43			43								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	3			Specialty Tier	4	11	1	1	5	1		110	01		110	1				30		100	1	2				30		100	30		31											469.98	33		33				475.85	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	3			Select Care Drugs	4	01	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				0.00			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			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	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		100	1	2				30		100	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		100	1	2				30		100	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		100	1	2				30		100	30		31											95.98	41		41				83.66	36		36										41		41				36		36			41			41								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		100	1	2				30		100	30		31											418.81	31		31				410.79	31		31										31		31				31		31			31			31								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		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		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	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		21.00					0.00		0.00											7.00		14.00				0.00		0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00		21.00	0.00		0.00	7.00		14.00	0.00		0.00	7.00		7.00
H0104	015	0	1	04	01	H0104_015_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		100	1	2				30		100	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	0.26	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
H0104	015	0	1	04	01	H0104_015_0	5			Preferred Brand	4	10	1	2	3	1		110	01		110	1				30		100	1	2				30		100	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
H0104	015	0	1	04	01	H0104_015_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		100	1	2				30		100	30		31											84.97	38		38				73.59	33		33										38		38				33		33			38			38								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
H0104	015	0	1	04	01	H0104_015_0	5			Specialty Tier	4	11	1	1	5	1		110	01		110	1				30		100	1	2				30		100	30		31											498.94	33		33				444.49	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0104	016	0	1	04	01	H0104_016_0	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H0104	016	0	1	04	01	H0104_016_0	7			Generic	4	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	13.00		39.00																			13.00		26.00																13.00				13.00		0.43			0.43			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00		39.00				13.00		26.00				13.00		13.00
H0104	016	0	1	04	01	H0104_016_0	7			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				52.96	20		20																		20		20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		70.00				35.00		35.00
H0104	016	0	1	04	01	H0104_016_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				73.08	40		40																		40		40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		70.00				35.00		35.00
H0104	016	0	1	04	01	H0104_016_0	7			Specialty Tier	4	11	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				367.73	27		27																		27		27															27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0107	003	0	1	04	01	H0107_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H0107	003	0	1	04	01	H0107_003_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H0107	003	0	1	04	01	H0107_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											51.47	50	50	50				56.31	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
H0107	003	0	1	04	01	H0107_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											681.91	33						471.70	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0107	004	0	1	04	01	H0107_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H0107	004	0	1	04	01	H0107_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H0107	004	0	1	04	01	H0107_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											46.03	50	50	50				52.97	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
H0107	004	0	1	04	01	H0107_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											698.09	33						527.28	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0107	005	0	1	04	01	H0107_005_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H0107	005	0	1	04	01	H0107_005_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H0107	005	0	1	04	01	H0107_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	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	005	0	1	04	01	H0107_005_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											97.94	40	40	40				98.10	37	37	37										40	40	40				37	37	37			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
H0107	005	0	1	04	01	H0107_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											528.17	25						388.87	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0107	007	0	1	04	01	H0107_007_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H0107	007	0	1	04	01	H0107_007_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H0107	007	0	1	04	01	H0107_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	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	007	0	1	04	01	H0107_007_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											98.69	30	30	30				89.15	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	105.00	35.00	70.00	105.00	35.00		35.00
H0107	007	0	1	04	01	H0107_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											494.26	25						489.65	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0107	010	0	1	04	01	H0107_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H0107	010	0	1	04	01	H0107_010_0	11			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H0107	010	0	1	04	01	H0107_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	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	010	0	1	04	01	H0107_010_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											100.95	25	25	25				93.76	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
H0107	010	0	1	04	01	H0107_010_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											378.32	25						377.14	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0111	001	0	1	04	01	H0111_001_0	5			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	5			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																								
H0111	001	0	1	04	01	H0111_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.66	25	25	25				154.66	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
H0111	001	0	1	04	01	H0111_001_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											50.69	46	46	46				50.69	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
H0111	001	0	1	04	01	H0111_001_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, Select Care Drugs																								
H0111	001	0	1	04	01	H0111_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0111	004	0	1	04	01	H0111_004_0	5		N	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					12.00	24.00	36.00											19.00	38.00	57.00				12.00	24.00	0.00				19.00				19.00			0.63	0.4		0.63	0.4	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0111	004	0	1	04	01	H0111_004_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0111	004	0	1	04	01	H0111_004_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											119.39	20	20	20				119.39	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
H0111	004	0	1	04	01	H0111_004_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											36.59	40	40	40				36.59	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
H0111	004	0	1	04	01	H0111_004_0	5		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, Select Care Drugs																								
H0111	004	0	1	04	01	H0111_004_0	5		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	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0137	001	0	1	48	05	H0137_001_0	6			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	6			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	6			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	6			Non-Preferred Brand Drugs	4	11		2	4	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	6			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	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				99.20	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		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	31																																					31			31								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	3		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	3		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	3		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	3		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	3		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	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				99.16	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		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	29																																					29			29								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	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				99.16	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		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	29																																					29			29								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	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				99.82	41	41	41																								41	41	41				41	41	41			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
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	30																																					30			30								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	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				99.48	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
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	29																																					29			29								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	3		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	3		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	3		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	3		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	3		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	3			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	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	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	3			Preferred Brand	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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				98.83	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		35.00
H0154	020	0	1	01	01	H0154_020_0	3			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	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.54	25	25	25				158.54	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
H0174	002	0	1	01	01	H0174_002_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											61.53	42	42	42				61.53	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
H0174	002	0	1	01	01	H0174_002_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, Select Care Drugs																								
H0174	002	0	1	01	01	H0174_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0174	009	0	1	01	01	H0174_009_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0174	009	0	1	01	01	H0174_009_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0174	009	0	1	01	01	H0174_009_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											147.64	23	23	23				147.64	23	23	23										23	23	23				23	23	23			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
H0174	009	0	1	01	01	H0174_009_0	5			Non-Preferred Drug	3	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	200.00				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
H0174	009	0	1	01	01	H0174_009_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																								
H0174	009	0	1	01	01	H0174_009_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								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																								
H0174	010	0	1	01	01	H0174_010_0	5			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	5			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	010	0	1	01	01	H0174_010_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.54	25	25	25				159.54	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
H0174	010	0	1	01	01	H0174_010_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											67.38	44	44	44				67.38	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
H0174	010	0	1	01	01	H0174_010_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, Select Care Drugs																								
H0174	010	0	1	01	01	H0174_010_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																								
H0174	014	0	1	01	01	H0174_014_0	5			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	5			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	014	0	1	01	01	H0174_014_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.00	25	25	25				155.00	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
H0174	014	0	1	01	01	H0174_014_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											57.18	43	43	43				57.18	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	014	0	1	01	01	H0174_014_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, Select Care Drugs																								
H0174	014	0	1	01	01	H0174_014_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																								
H0174	015	0	1	01	01	H0174_015_0	5			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	5			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	015	0	1	01	01	H0174_015_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.18	25	25	25				158.18	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
H0174	015	0	1	01	01	H0174_015_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											61.22	42	42	42				61.22	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
H0174	015	0	1	01	01	H0174_015_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, Select Care Drugs																								
H0174	015	0	1	01	01	H0174_015_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																								
H0174	016	0	1	01	01	H0174_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			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	5			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	016	0	1	01	01	H0174_016_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.09	25	25	25				164.09	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
H0174	016	0	1	01	01	H0174_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											63.71	40	40	40				63.71	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
H0174	016	0	1	01	01	H0174_016_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, Select Care Drugs																								
H0174	016	0	1	01	01	H0174_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																								
H0174	017	0	1	01	01	H0174_017_0	5			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	5			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	017	0	1	01	01	H0174_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.16	25	25	25				161.16	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
H0174	017	0	1	01	01	H0174_017_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											70.35	37	37	37				70.35	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
H0174	017	0	1	01	01	H0174_017_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, Select Care Drugs																								
H0174	017	0	1	01	01	H0174_017_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																								
H0174	018	0	1	01	01	H0174_018_0	5			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	018	0	1	01	01	H0174_018_0	5			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	018	0	1	01	01	H0174_018_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.98	25	25	25				157.98	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
H0174	018	0	1	01	01	H0174_018_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											68.06	44	44	44				68.06	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
H0174	018	0	1	01	01	H0174_018_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, Select Care Drugs																								
H0174	018	0	1	01	01	H0174_018_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																								
H0174	019	0	1	01	01	H0174_019_0	5			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	5			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	019	0	1	01	01	H0174_019_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											160.04	25	25	25				160.04	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
H0174	019	0	1	01	01	H0174_019_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											96.48	46	46	46				96.48	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
H0174	019	0	1	01	01	H0174_019_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, Select Care Drugs																								
H0174	019	0	1	01	01	H0174_019_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																								
H0174	020	0	1	01	01	H0174_020_0	5			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	5			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	020	0	1	01	01	H0174_020_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											163.34	25	25	25				163.34	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
H0174	020	0	1	01	01	H0174_020_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											71.54	43	43	43				71.54	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	020	0	1	01	01	H0174_020_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, Select Care Drugs																								
H0174	020	0	1	01	01	H0174_020_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																								
H0174	021	0	1	01	01	H0174_021_0	5			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	5			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	021	0	1	01	01	H0174_021_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											168.59	25	25	25				168.59	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
H0174	021	0	1	01	01	H0174_021_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											87.93	37	37	37				87.93	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
H0174	021	0	1	01	01	H0174_021_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, Select Care Drugs																								
H0174	021	0	1	01	01	H0174_021_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																								
H0192	001	0	1	48	05	H0192_001_0	6			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	6			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	6			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	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																								
H0270	001	0	1	04	01	H0270_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0270	001	0	1	04	01	H0270_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											161.23	25	25	25				161.23	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
H0270	001	0	1	04	01	H0270_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											49.13	39	39	39				49.13	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
H0270	001	0	1	04	01	H0270_001_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, Select Care Drugs																								
H0270	001	0	1	04	01	H0270_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																								
H0292	001	0	1	01	01	H0292_001_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
H0292	001	0	1	01	01	H0292_001_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
H0292	001	0	1	01	01	H0292_001_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		95.00	35.00		35.00
H0292	001	0	1	01	01	H0292_001_0	4			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																								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
H0292	001	0	1	01	01	H0292_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 Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0292	002	0	1	01	01	H0292_002_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H0292	002	0	1	01	01	H0292_002_0	3			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																								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		35.00
H0292	002	0	1	01	01	H0292_002_0	3			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
H0292	003	0	1	01	01	H0292_003_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
H0292	003	0	1	01	01	H0292_003_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
H0292	003	0	1	01	01	H0292_003_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		95.00	35.00		35.00
H0292	003	0	1	01	01	H0292_003_0	4			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																								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		35.00
H0292	003	0	1	01	01	H0292_003_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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	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			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				189.00	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
H0294	012	0	1	04	01	H0294_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																								
H0294	012	0	1	04	01	H0294_012_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	012	0	1	04	01	H0294_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
H0294	012	0	1	04	01	H0294_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0294	012	0	1	04	01	H0294_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H0294	015	0	1	04	01	H0294_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																								
H0294	015	0	1	04	01	H0294_015_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	015	0	1	04	01	H0294_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
H0294	015	0	1	04	01	H0294_015_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0294	015	0	1	04	01	H0294_015_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
H0294	016	0	1	04	01	H0294_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																								
H0294	016	0	1	04	01	H0294_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																								
H0294	016	0	1	04	01	H0294_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
H0294	016	0	1	04	01	H0294_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0294	016	0	1	04	01	H0294_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				169.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				193.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				159.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				135.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				186.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				163.00	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
H0294	037	0	1	04	01	H0294_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																								
H0294	037	0	1	04	01	H0294_037_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	037	0	1	04	01	H0294_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
H0294	037	0	1	04	01	H0294_037_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0294	037	0	1	04	01	H0294_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				145.00	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
H0294	038	0	1	04	01	H0294_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																								
H0294	038	0	1	04	01	H0294_038_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	038	0	1	04	01	H0294_038_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	038	0	1	04	01	H0294_038_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0294	038	0	1	04	01	H0294_038_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H0294	039	0	1	04	01	H0294_039_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	039	0	1	04	01	H0294_039_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	039	0	1	04	01	H0294_039_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	039	0	1	04	01	H0294_039_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0294	039	0	1	04	01	H0294_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				123.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				125.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				160.00	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
H0294	047	0	1	04	01	H0294_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																								
H0294	047	0	1	04	01	H0294_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																								
H0294	047	0	1	04	01	H0294_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
H0294	047	0	1	04	01	H0294_047_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0294	047	0	1	04	01	H0294_047_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				160.00	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
H0302	001	0	1	01	01	H0302_001_0	15			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	15			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	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	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	15			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	15			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	15			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	15			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	15			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	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	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	15			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	15			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	15			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	15			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	15			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	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	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	15			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	15			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	15			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	004	0	1	02	01	H0332_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								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	004	0	1	02	01	H0332_004_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					5.00	10.00	12.50											15.00	30.00	45.00				5.00	10.00	12.50				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	004	0	1	02	01	H0332_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					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	004	0	1	02	01	H0332_004_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											96.45	40	40	40				72.15	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	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	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1047.88	30						1669.19	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
H0332	004	0	1	02	01	H0332_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		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			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	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	009	0	1	01	01	H0332_009_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	12.50											15.00	30.00	45.00				5.00	10.00	12.50				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	009	0	1	01	01	H0332_009_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	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	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.98	40	40	40				71.16	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	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	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											841.27	30						1806.56	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
H0332	009	0	1	01	01	H0332_009_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																								
H0336	001	0	1	48	05	H0336_001_0	5			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	5			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	5			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	5			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	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					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										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	8			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					5.00	10.00	15.00					5.00	10.00	10.00																15.00				5.00			0.50	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	5.00	10.00	15.00	5.00	10.00	10.00				15.00		5.00
H0342	001	0	1	04	01	H0342_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											64.75	25	25	25				67.85	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											68.46	50	50	50				58.79	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H0342	001	0	1	04	01	H0342_001_0	8			Vaccines	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																								
H0351	038	0	1	01	01	H0351_038_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																								
H0351	038	0	1	01	01	H0351_038_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0351	038	0	1	01	01	H0351_038_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											170.20	25	25	25				170.20	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											47.97	35	35	35				47.97	35	35	35										35	35	35				35	35	35			35			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
H0351	038	0	1	01	01	H0351_038_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, Select Care Drugs																								
H0351	038	0	1	01	01	H0351_038_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										0.00	0.00	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	053	0	1	01	01	H0351_053_0	5			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	053	0	1	01	01	H0351_053_0	5			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																								
H0351	053	0	1	01	01	H0351_053_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.25	25	25	25				157.25	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
H0351	053	0	1	01	01	H0351_053_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											70.66	44	44	44				69.05	43	43	43										44	44	44				43	43	43			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	053	0	1	01	01	H0351_053_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, Select Care Drugs																								
H0351	053	0	1	01	01	H0351_053_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																								
H0351	054	0	1	01	01	H0351_054_0	5			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	054	0	1	01	01	H0351_054_0	5			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																								
H0351	054	0	1	01	01	H0351_054_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.57	25	25	25				156.57	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
H0351	054	0	1	01	01	H0351_054_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											57.72	36	36	36				57.72	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
H0351	054	0	1	01	01	H0351_054_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, Select Care Drugs																								
H0351	054	0	1	01	01	H0351_054_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																								
H0351	057	0	1	01	01	H0351_057_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																								
H0351	057	0	1	01	01	H0351_057_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0351	057	0	1	01	01	H0351_057_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											184.38	25	25	25				184.38	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
H0351	057	0	1	01	01	H0351_057_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											53.15	34	34	34				51.59	33	33	33										34	34	34				33	33	33			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	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, Select Care Drugs																								
H0351	057	0	1	01	01	H0351_057_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								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	20.00	0.00				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	0.00	10.00		10.00
H0351	063	0	1	01	01	H0351_063_0	5			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	063	0	1	01	01	H0351_063_0	5			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																								
H0351	063	0	1	01	01	H0351_063_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.66	25	25	25				153.66	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
H0351	063	0	1	01	01	H0351_063_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											73.22	41	41	41				73.22	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
H0351	063	0	1	01	01	H0351_063_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, Select Care Drugs																								
H0351	063	0	1	01	01	H0351_063_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																								
H0351	064	0	1	01	01	H0351_064_0	5			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	064	0	1	01	01	H0351_064_0	5			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																								
H0351	064	0	1	01	01	H0351_064_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.06	25	25	25				157.06	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
H0351	064	0	1	01	01	H0351_064_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											66.87	37	37	37				63.26	35	35	35										37	37	37				35	35	35			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	064	0	1	01	01	H0351_064_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, Select Care Drugs																								
H0351	064	0	1	01	01	H0351_064_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																								
H0351	065	0	1	01	01	H0351_065_0	5			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	065	0	1	01	01	H0351_065_0	5			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																								
H0351	065	0	1	01	01	H0351_065_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.40	25	25	25				151.40	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
H0351	065	0	1	01	01	H0351_065_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											77.23	43	43	43				77.23	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
H0351	065	0	1	01	01	H0351_065_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, Select Care Drugs																								
H0351	065	0	1	01	01	H0351_065_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																								
H0351	067	0	1	02	01	H0351_067_0	5			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	067	0	1	02	01	H0351_067_0	5			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																								
H0351	067	0	1	02	01	H0351_067_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.40	25	25	25				151.40	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
H0351	067	0	1	02	01	H0351_067_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											77.23	43	43	43				77.23	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
H0351	067	0	1	02	01	H0351_067_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, Select Care Drugs																								
H0351	067	0	1	02	01	H0351_067_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																								
H0351	069	0	1	02	01	H0351_069_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																								
H0351	069	0	1	02	01	H0351_069_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0351	069	0	1	02	01	H0351_069_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											171.46	25	25	25				171.46	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	069	0	1	02	01	H0351_069_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											47.51	31	31	31				47.51	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
H0351	069	0	1	02	01	H0351_069_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, Select Care Drugs																								
H0351	069	0	1	02	01	H0351_069_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										0.00	0.00	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	070	0	1	02	01	H0351_070_0	5			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	070	0	1	02	01	H0351_070_0	5			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																								
H0351	070	0	1	02	01	H0351_070_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.40	25	25	25				151.40	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
H0351	070	0	1	02	01	H0351_070_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											77.23	43	43	43				77.23	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
H0351	070	0	1	02	01	H0351_070_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, Select Care Drugs																								
H0351	070	0	1	02	01	H0351_070_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																								
H0354	001	0	1	01	01	H0354_001_0	4			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
H0354	001	0	1	01	01	H0354_001_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											762.50	33						779.73	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
H0354	027	0	1	01	01	H0354_027_0	4			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, 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	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											449.39	33						389.03	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	4			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	4			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
H0354	028	0	1	01	01	H0354_028_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											688.58	33						796.02	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
H0354	029	0	1	01	01	H0354_029_0	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H0354	029	0	1	01	01	H0354_029_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H0354	029	0	1	01	01	H0354_029_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											811.01	33						807.77	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
H0354	030	0	1	01	01	H0354_030_0	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H0354	030	0	1	01	01	H0354_030_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H0354	030	0	1	01	01	H0354_030_0	4			Preferred Brand	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	030	0	1	01	01	H0354_030_0	4			Non-Preferred Drug	4	11	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	030	0	1	01	01	H0354_030_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											810.87	33						808.15	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
H0432	003	0	1	02	01	H0432_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																								
H0432	003	0	1	02	01	H0432_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																								
H0432	003	0	1	02	01	H0432_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
H0432	003	0	1	02	01	H0432_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0432	003	0	1	02	01	H0432_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				192.00	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
H0432	004	0	1	02	01	H0432_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																								
H0432	004	0	1	02	01	H0432_004_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																								
H0432	004	0	1	02	01	H0432_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
H0432	004	0	1	02	01	H0432_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0432	004	0	1	02	01	H0432_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				193.00	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
H0432	017	0	1	02	01	H0432_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																								
H0432	017	0	1	02	01	H0432_017_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																								
H0432	017	0	1	02	01	H0432_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										25.00		75.00						75.00			65.00	25.00		25.00
H0432	017	0	1	02	01	H0432_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0432	017	0	1	02	01	H0432_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				157.00	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
H0439	003	1	1	01	01	H0439_003_1	5			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
H0439	003	1	1	01	01	H0439_003_1	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	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	003	1	1	01	01	H0439_003_1	5			Preferred Brand	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	003	1	1	01	01	H0439_003_1	5			Non-Preferred Drug	4	11	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	003	1	1	01	01	H0439_003_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											866.16	33						695.03	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
H0439	003	2	1	01	01	H0439_003_2	5			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
H0439	003	2	1	01	01	H0439_003_2	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	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	003	2	1	01	01	H0439_003_2	5			Preferred Brand	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	003	2	1	01	01	H0439_003_2	5			Non-Preferred Drug	4	11	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	003	2	1	01	01	H0439_003_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											866.16	33						695.03	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
H0439	006	0	1	01	01	H0439_006_0	5			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
H0439	006	0	1	01	01	H0439_006_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	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	006	0	1	01	01	H0439_006_0	5			Preferred Brand	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	5			Non-Preferred Drug	4	11	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	006	0	1	01	01	H0439_006_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											978.86	33						657.62	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
H0439	008	0	1	01	01	H0439_008_0	5			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
H0439	008	0	1	01	01	H0439_008_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	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	008	0	1	01	01	H0439_008_0	5			Preferred Brand	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	008	0	1	01	01	H0439_008_0	5			Non-Preferred Drug	4	11	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	008	0	1	01	01	H0439_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											848.24	33						694.69	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
H0439	009	0	1	01	01	H0439_009_0	5			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
H0439	009	0	1	01	01	H0439_009_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	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	5			Preferred Brand	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	5			Non-Preferred Drug	4	11	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	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											837.48	33						745.78	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
H0439	010	0	1	01	01	H0439_010_0	5			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
H0439	010	0	1	01	01	H0439_010_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	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	010	0	1	01	01	H0439_010_0	5			Preferred Brand	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	5			Non-Preferred Drug	4	11	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	010	0	1	01	01	H0439_010_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											741.85	33						717.24	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
H0439	011	0	1	01	01	H0439_011_0	5			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
H0439	011	0	1	01	01	H0439_011_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	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	011	0	1	01	01	H0439_011_0	5			Preferred Brand	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	011	0	1	01	01	H0439_011_0	5			Non-Preferred Drug	4	11	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	011	0	1	01	01	H0439_011_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											957.29	33						769.23	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
H0439	013	0	1	01	01	H0439_013_0	5			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
H0439	013	0	1	01	01	H0439_013_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	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	5			Preferred Brand	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	5			Non-Preferred Drug	4	11	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	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											797.09	33						639.84	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
H0439	015	1	1	01	01	H0439_015_1	5			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
H0439	015	1	1	01	01	H0439_015_1	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	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	015	1	1	01	01	H0439_015_1	5			Preferred Brand	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	015	1	1	01	01	H0439_015_1	5			Non-Preferred Drug	4	11	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	015	1	1	01	01	H0439_015_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											776.68	33						631.97	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
H0439	015	2	1	01	01	H0439_015_2	5			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
H0439	015	2	1	01	01	H0439_015_2	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	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	015	2	1	01	01	H0439_015_2	5			Preferred Brand	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	015	2	1	01	01	H0439_015_2	5			Non-Preferred Drug	4	11	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	015	2	1	01	01	H0439_015_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											776.68	33						631.97	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
H0473	001	0	1	04	01	H0473_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																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, 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	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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
H0473	001	0	1	04	01	H0473_001_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		95.00	35.00		35.00
H0473	001	0	1	04	01	H0473_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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
H0473	001	0	1	04	01	H0473_001_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
H0473	003	0	1	04	01	H0473_003_0	4			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	4			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	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		95.00	35.00		35.00
H0473	003	0	1	04	01	H0473_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	42		42																								42		42				42		42			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
H0473	003	0	1	04	01	H0473_003_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
H0473	004	0	1	04	01	H0473_004_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
H0473	004	0	1	04	01	H0473_004_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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
H0473	004	0	1	04	01	H0473_004_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		95.00	35.00		35.00
H0473	004	0	1	04	01	H0473_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H0473	004	0	1	04	01	H0473_004_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
H0473	005	0	1	04	01	H0473_005_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
H0473	005	0	1	04	01	H0473_005_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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
H0473	005	0	1	04	01	H0473_005_0	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		95.00	35.00		35.00
H0473	005	0	1	04	01	H0473_005_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H0473	005	0	1	04	01	H0473_005_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
H0480	001	0	1	48	05	H0480_001_0	4			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	4			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	4			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															
H0504	015	0	1	01	01	H0504_015_0	8			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	8			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	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	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	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	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	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																								
H0504	017	0	1	01	01	H0504_017_0	8			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	8			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	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	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	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	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	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																								
H0504	021	0	1	01	01	H0504_021_0	8			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	8			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	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	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	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	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	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																								
H0504	026	0	1	01	01	H0504_026_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	026	0	1	01	01	H0504_026_0	7			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	7			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	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	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	028	0	1	01	01	H0504_028_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	028	0	1	01	01	H0504_028_0	7			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	35.00	70.00	87.50			87.50				35.00		35.00
H0504	028	0	1	01	01	H0504_028_0	7			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	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	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	038	0	1	01	01	H0504_038_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	038	0	1	01	01	H0504_038_0	7			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	038	0	1	01	01	H0504_038_0	7			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	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	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	039	0	1	01	01	H0504_039_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	039	0	1	01	01	H0504_039_0	7			Generic	4	01	3	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	039	0	1	01	01	H0504_039_0	7			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	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	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	040	0	1	01	01	H0504_040_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	040	0	1	01	01	H0504_040_0	7			Generic	4	01	3	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	35.00	70.00	87.50			87.50				35.00		35.00
H0504	040	0	1	01	01	H0504_040_0	7			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	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	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	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			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	100	2	2			100				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	041	0	1	01	01	H0504_041_0	7			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	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	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	043	0	1	01	01	H0504_043_0	7			Generic	4	01	3	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	35.00	70.00	87.50			87.50				35.00		35.00
H0504	043	0	1	01	01	H0504_043_0	7			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	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	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	047	0	1	01	01	H0504_047_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	047	0	1	01	01	H0504_047_0	7			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	047	0	1	01	01	H0504_047_0	7			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	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	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																								
H0523	022	0	1	02	01	H0523_022_0	5			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	022	0	1	02	01	H0523_022_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	022	0	1	02	01	H0523_022_0	5			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.04	24	24	24				104.61	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
H0523	022	0	1	02	01	H0523_022_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											47.83	25	25	25				40.80	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
H0523	022	0	1	02	01	H0523_022_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											640.64	25						807.58	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
H0523	065	0	1	02	01	H0523_065_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	065	0	1	02	01	H0523_065_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	065	0	1	02	01	H0523_065_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.64	24	24	24				106.75	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
H0523	065	0	1	02	01	H0523_065_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											45.85	25	25	25				37.90	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
H0523	065	0	1	02	01	H0523_065_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											730.71	25						678.50	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
H0523	070	0	1	02	01	H0523_070_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	070	0	1	02	01	H0523_070_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0523	070	0	1	02	01	H0523_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											70.88	25	25	25				93.16	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
H0523	070	0	1	02	01	H0523_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											43.07	35	35	35				33.21	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
H0523	070	0	1	02	01	H0523_070_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1125.82	33						1157.22	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
H0523	072	0	1	02	01	H0523_072_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	072	0	1	02	01	H0523_072_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	072	0	1	02	01	H0523_072_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.70	24	24	24				104.92	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
H0523	072	0	1	02	01	H0523_072_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.37	25	25	25				38.71	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
H0523	072	0	1	02	01	H0523_072_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											782.34	25						747.67	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
H0523	073	0	1	02	01	H0523_073_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	073	0	1	02	01	H0523_073_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	073	0	1	02	01	H0523_073_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.01	24	24	24				116.02	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
H0523	073	0	1	02	01	H0523_073_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.00	25	25	25				42.28	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
H0523	073	0	1	02	01	H0523_073_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											741.75	25						696.08	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
H0523	074	0	1	02	01	H0523_074_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	074	0	1	02	01	H0523_074_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0523	074	0	1	02	01	H0523_074_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.19	25	25	25				98.34	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
H0523	074	0	1	02	01	H0523_074_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											41.85	26	26	26				35.67	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											804.69	30						800.58	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
H0523	075	0	1	02	01	H0523_075_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	075	0	1	02	01	H0523_075_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0523	075	0	1	02	01	H0523_075_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.43	25	25	25				82.90	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
H0523	075	0	1	02	01	H0523_075_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.38	35	35	35				28.72	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
H0523	075	0	1	02	01	H0523_075_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											973.37	33						983.58	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
H0523	076	0	1	02	01	H0523_076_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	076	0	1	02	01	H0523_076_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0523	076	0	1	02	01	H0523_076_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.41	25	25	25				97.40	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
H0523	076	0	1	02	01	H0523_076_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											41.77	26	26	26				35.89	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											795.93	30						791.99	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
H0523	078	0	1	02	01	H0523_078_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	078	0	1	02	01	H0523_078_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0523	078	0	1	02	01	H0523_078_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.15	25	25	25				99.41	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
H0523	078	0	1	02	01	H0523_078_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											41.84	26	26	26				35.38	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											819.96	30						809.33	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
H0523	080	0	1	02	01	H0523_080_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0523	080	0	1	02	01	H0523_080_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0523	080	0	1	02	01	H0523_080_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.12	25	25	25				97.03	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
H0523	080	0	1	02	01	H0523_080_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											41.73	26	26	26				35.98	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											793.00	30						789.33	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
H0524	003	0	1	01	01	H0524_003_0	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, Vaccines										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	7			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										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	7			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										35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	003	0	1	01	01	H0524_003_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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	008	0	1	01	01	H0524_008_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	013	0	1	01	01	H0524_013_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	015	0	1	01	01	H0524_015_0	8			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	015	0	1	01	01	H0524_015_0	8			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										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	8			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										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	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																			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										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	8			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										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	8			Vaccines	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																								
H0524	031	0	1	01	01	H0524_031_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	032	0	1	01	01	H0524_032_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	033	0	1	01	01	H0524_033_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	034	0	1	01	01	H0524_034_0	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, Vaccines										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	7			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										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	7			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										35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	034	0	1	01	01	H0524_034_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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	035	0	1	01	01	H0524_035_0	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, Vaccines										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	7			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										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	7			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										35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	035	0	1	01	01	H0524_035_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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	036	0	1	01	01	H0524_036_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	037	0	1	01	01	H0524_037_0	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, Vaccines										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	7			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										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	7			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										35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	037	0	1	01	01	H0524_037_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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	038	0	1	01	01	H0524_038_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	039	0	1	01	01	H0524_039_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	040	0	1	01	01	H0524_040_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	041	0	1	01	01	H0524_041_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	042	0	1	01	01	H0524_042_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	043	0	1	01	01	H0524_043_0	7			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										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	046	0	1	01	01	H0524_046_0	7			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										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	051	0	1	01	01	H0524_051_0	7			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										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	054	0	1	01	01	H0524_054_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	059	0	1	01	01	H0524_059_0	7			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	059	0	1	01	01	H0524_059_0	7			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										4.00	8.00	12.00				4.00	8.00	12.00				4.00		4.00
H0524	059	0	1	01	01	H0524_059_0	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	060	0	1	01	01	H0524_060_0	7			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	060	0	1	01	01	H0524_060_0	7			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										13.00	26.00	39.00				13.00	26.00	36.00				13.00		13.00
H0524	060	0	1	01	01	H0524_060_0	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	061	0	1	01	01	H0524_061_0	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, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	061	0	1	01	01	H0524_061_0	7			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										4.00	8.00	12.00				4.00	8.00	12.00				4.00		4.00
H0524	061	0	1	01	01	H0524_061_0	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	062	0	1	01	01	H0524_062_0	7			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	062	0	1	01	01	H0524_062_0	7			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	062	0	1	01	01	H0524_062_0	7			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										25.00	50.00	75.00				25.00	50.00	75.00				25.00		25.00
H0524	062	0	1	01	01	H0524_062_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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	063	0	1	01	01	H0524_063_0	8			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	063	0	1	01	01	H0524_063_0	8			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			0.22			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H0524	063	0	1	01	01	H0524_063_0	8			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										35.00	70.00	105.00				35.00	70.00	80.00				35.00		35.00
H0524	063	0	1	01	01	H0524_063_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	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										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	8			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										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	8			Vaccines	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																								
H0524	064	0	1	01	01	H0524_064_0	7			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										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	065	0	1	01	01	H0524_065_0	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, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	065	0	1	01	01	H0524_065_0	7			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										2.00	4.00	6.00				2.00	4.00	6.00				2.00		2.00
H0524	065	0	1	01	01	H0524_065_0	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	078	0	1	01	01	H0524_078_0	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, Vaccines										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	7			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										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	7			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										35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	078	0	1	01	01	H0524_078_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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	081	0	1	01	01	H0524_081_0	8			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	081	0	1	01	01	H0524_081_0	8			Generic	4	11	1	2	2	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	081	0	1	01	01	H0524_081_0	8			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	32.00	64.00	96.00																			32.00	64.00	64.00																32.00				32.00		1.06			1.06			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	081	0	1	01	01	H0524_081_0	8			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	081	0	1	01	01	H0524_081_0	8			Vaccines	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																								
H0524	082	0	1	01	01	H0524_082_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0524	083	0	1	01	01	H0524_083_0	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, Vaccines										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	7			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										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	7			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										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	7			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										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	7			Vaccines	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																								
H0543	013	0	1	02	01	H0543_013_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	013	0	1	02	01	H0543_013_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	013	0	1	02	01	H0543_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
H0543	013	0	1	02	01	H0543_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	013	0	1	02	01	H0543_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				214.00	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
H0543	035	0	1	02	01	H0543_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																								
H0543	035	0	1	02	01	H0543_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																								
H0543	035	0	1	02	01	H0543_035_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
H0543	035	0	1	02	01	H0543_035_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	035	0	1	02	01	H0543_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				126.00	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
H0543	036	0	1	02	01	H0543_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																								
H0543	036	0	1	02	01	H0543_036_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																								
H0543	036	0	1	02	01	H0543_036_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
H0543	036	0	1	02	01	H0543_036_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	036	0	1	02	01	H0543_036_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				162.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				197.00	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
H0543	086	0	1	02	01	H0543_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																								
H0543	086	0	1	02	01	H0543_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																								
H0543	086	0	1	02	01	H0543_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
H0543	086	0	1	02	01	H0543_086_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	086	0	1	02	01	H0543_086_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				191.00	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
H0543	140	0	1	02	01	H0543_140_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	140	0	1	02	01	H0543_140_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
H0543	140	0	1	02	01	H0543_140_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	140	0	1	02	01	H0543_140_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				143.00	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
H0543	145	0	1	02	01	H0543_145_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																								
H0543	145	0	1	02	01	H0543_145_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																								
H0543	145	0	1	02	01	H0543_145_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
H0543	145	0	1	02	01	H0543_145_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	145	0	1	02	01	H0543_145_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				214.00	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
H0543	146	0	1	02	01	H0543_146_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	146	0	1	02	01	H0543_146_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
H0543	146	0	1	02	01	H0543_146_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	146	0	1	02	01	H0543_146_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				190.00	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
H0543	147	0	1	02	01	H0543_147_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	147	0	1	02	01	H0543_147_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
H0543	147	0	1	02	01	H0543_147_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	147	0	1	02	01	H0543_147_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				170.00	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
H0543	151	0	1	02	01	H0543_151_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	151	0	1	02	01	H0543_151_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	151	0	1	02	01	H0543_151_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	151	0	1	02	01	H0543_151_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				201.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				199.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				181.00	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
H0543	167	0	1	02	01	H0543_167_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	167	0	1	02	01	H0543_167_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
H0543	167	0	1	02	01	H0543_167_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	167	0	1	02	01	H0543_167_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				202.00	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
H0543	168	0	1	02	01	H0543_168_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	168	0	1	02	01	H0543_168_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	168	0	1	02	01	H0543_168_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	168	0	1	02	01	H0543_168_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				209.00	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
H0543	169	0	1	02	01	H0543_169_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	169	0	1	02	01	H0543_169_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	169	0	1	02	01	H0543_169_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	169	0	1	02	01	H0543_169_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H0543	170	0	1	02	01	H0543_170_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	170	0	1	02	01	H0543_170_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	170	0	1	02	01	H0543_170_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	170	0	1	02	01	H0543_170_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				203.00	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
H0543	176	0	1	02	01	H0543_176_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	176	0	1	02	01	H0543_176_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
H0543	176	0	1	02	01	H0543_176_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	176	0	1	02	01	H0543_176_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				178.00	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
H0543	188	0	1	02	01	H0543_188_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	188	0	1	02	01	H0543_188_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
H0543	188	0	1	02	01	H0543_188_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	188	0	1	02	01	H0543_188_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
H0543	189	0	1	02	01	H0543_189_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	189	0	1	02	01	H0543_189_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
H0543	189	0	1	02	01	H0543_189_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	189	0	1	02	01	H0543_189_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
H0543	191	0	1	02	01	H0543_191_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	191	0	1	02	01	H0543_191_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
H0543	191	0	1	02	01	H0543_191_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	191	0	1	02	01	H0543_191_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				201.00	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
H0543	193	0	1	02	01	H0543_193_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	193	0	1	02	01	H0543_193_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
H0543	193	0	1	02	01	H0543_193_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	193	0	1	02	01	H0543_193_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				194.00	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
H0543	196	0	1	02	01	H0543_196_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	196	0	1	02	01	H0543_196_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
H0543	196	0	1	02	01	H0543_196_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	196	0	1	02	01	H0543_196_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				156.00	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
H0543	204	0	1	02	01	H0543_204_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																								
H0543	204	0	1	02	01	H0543_204_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																								
H0543	204	0	1	02	01	H0543_204_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		141.00													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		105.00			105.00			95.00	35.00		35.00
H0543	204	0	1	02	01	H0543_204_0	5			Non-Preferred Drug	4	11	1	2	4	1		010	01		010	1				30			2	2				30			30		31								100.00							100.00													100.00						100.00						100.00				100.00			3.33	3.33		3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
H0543	204	0	1	02	01	H0543_204_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											178.00	31						216.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				200.00	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
H0543	217	0	1	02	01	H0543_217_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	217	0	1	02	01	H0543_217_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	217	0	1	02	01	H0543_217_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	217	0	1	02	01	H0543_217_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
H0543	218	0	1	02	01	H0543_218_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	218	0	1	02	01	H0543_218_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	218	0	1	02	01	H0543_218_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	218	0	1	02	01	H0543_218_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				163.00	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
H0543	219	0	1	02	01	H0543_219_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	219	0	1	02	01	H0543_219_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	219	0	1	02	01	H0543_219_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	219	0	1	02	01	H0543_219_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				154.00	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
H0543	220	0	1	02	01	H0543_220_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	220	0	1	02	01	H0543_220_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	220	0	1	02	01	H0543_220_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	220	0	1	02	01	H0543_220_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
H0543	221	0	1	02	01	H0543_221_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	221	0	1	02	01	H0543_221_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	221	0	1	02	01	H0543_221_0	6			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	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	221	0	1	02	01	H0543_221_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
H0543	222	0	1	02	01	H0543_222_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	222	0	1	02	01	H0543_222_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
H0543	222	0	1	02	01	H0543_222_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	222	0	1	02	01	H0543_222_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
H0543	223	0	1	02	01	H0543_223_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	223	0	1	02	01	H0543_223_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
H0543	223	0	1	02	01	H0543_223_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	223	0	1	02	01	H0543_223_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H0543	224	0	1	02	01	H0543_224_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	224	0	1	02	01	H0543_224_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
H0543	224	0	1	02	01	H0543_224_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	224	0	1	02	01	H0543_224_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H0543	225	0	1	02	01	H0543_225_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																								
H0543	225	0	1	02	01	H0543_225_0	10			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	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										35.00		105.00						105.00			95.00	35.00		35.00
H0543	225	0	1	02	01	H0543_225_0	10			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	225	0	1	02	01	H0543_225_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				225.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				196.00	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
H0543	228	0	1	02	01	H0543_228_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	228	0	1	02	01	H0543_228_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
H0543	228	0	1	02	01	H0543_228_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	228	0	1	02	01	H0543_228_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				215.00	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
H0543	232	0	1	02	01	H0543_232_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	232	0	1	02	01	H0543_232_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
H0543	232	0	1	02	01	H0543_232_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	232	0	1	02	01	H0543_232_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
H0543	234	0	1	02	01	H0543_234_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H0543	234	0	1	02	01	H0543_234_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
H0543	234	0	1	02	01	H0543_234_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	234	0	1	02	01	H0543_234_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				180.00	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
H0543	236	0	1	02	01	H0543_236_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	236	0	1	02	01	H0543_236_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																								
H0543	236	0	1	02	01	H0543_236_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	236	0	1	02	01	H0543_236_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	236	0	1	02	01	H0543_236_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				205.00	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
H0543	237	0	1	02	01	H0543_237_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	237	0	1	02	01	H0543_237_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																								
H0543	237	0	1	02	01	H0543_237_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	237	0	1	02	01	H0543_237_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	237	0	1	02	01	H0543_237_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				196.00	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
H0543	238	0	1	02	01	H0543_238_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	238	0	1	02	01	H0543_238_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																								
H0543	238	0	1	02	01	H0543_238_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	238	0	1	02	01	H0543_238_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	238	0	1	02	01	H0543_238_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				199.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				188.00	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
H0543	251	0	1	02	01	H0543_251_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	251	0	1	02	01	H0543_251_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	251	0	1	02	01	H0543_251_0	6			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	251	0	1	02	01	H0543_251_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0543	251	0	1	02	01	H0543_251_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				207.00	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
H0544	002	0	1	02	01	H0544_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			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	02	01	H0544_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, Select Care Drugs																								
H0544	002	0	1	02	01	H0544_002_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											94.57	25	25	25				75.65	20	20	20				20	20	20															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	70.00				35.00		35.00
H0544	002	0	1	02	01	H0544_002_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											81.63	25	25	25				81.63	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		35.00
H0544	002	0	1	02	01	H0544_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																								
H0544	002	0	1	02	01	H0544_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
H0544	004	0	1	02	01	H0544_004_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	004	0	1	02	01	H0544_004_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	004	0	1	02	01	H0544_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								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			1.38	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
H0544	004	0	1	02	01	H0544_004_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											80.70	25	25	25				80.70	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		35.00
H0544	004	0	1	02	01	H0544_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																								
H0544	004	0	1	02	01	H0544_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
H0544	005	0	1	01	01	H0544_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	0.00	0.00	0.00																			0.00	0.00	0.00																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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0544	005	0	1	01	01	H0544_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																			47.00	94.00	94.00																47.00				47.00		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	70.00				35.00		35.00
H0544	005	0	1	01	01	H0544_005_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				61.53	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
H0544	005	0	1	01	01	H0544_005_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																								
H0544	005	0	1	01	01	H0544_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	0.00	0.00	0.00																			0.00	0.00	0.00																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	007	0	1	02	01	H0544_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								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	007	0	1	02	01	H0544_007_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																								
H0544	007	0	1	02	01	H0544_007_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											100.74	25	25	25				80.59	20	20	20				20	20	20															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	70.00				35.00		35.00
H0544	007	0	1	02	01	H0544_007_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											77.58	25	25	25				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	70.00	105.00				35.00		35.00
H0544	007	0	1	02	01	H0544_007_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	007	0	1	02	01	H0544_007_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	008	0	1	02	01	H0544_008_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	008	0	1	02	01	H0544_008_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																								
H0544	008	0	1	02	01	H0544_008_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											97.62	25	25	25				78.09	20	20	20				20	20	20															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	70.00				35.00		35.00
H0544	008	0	1	02	01	H0544_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											73.51	25	25	25				73.51	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		35.00
H0544	008	0	1	02	01	H0544_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																								
H0544	008	0	1	02	01	H0544_008_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	02	01	H0544_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0544	010	0	1	02	01	H0544_010_0	5			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	010	0	1	02	01	H0544_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								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			1.38	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
H0544	010	0	1	02	01	H0544_010_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											78.81	25	25	25				78.81	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		35.00
H0544	010	0	1	02	01	H0544_010_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																								
H0544	010	0	1	02	01	H0544_010_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			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	02	01	H0544_014_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, Select Care Drugs																								
H0544	014	0	1	02	01	H0544_014_0	5			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	02	01	H0544_014_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					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			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
H0544	014	0	1	02	01	H0544_014_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											83.42	25	25	25				83.42	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		35.00
H0544	014	0	1	02	01	H0544_014_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																								
H0544	014	0	1	02	01	H0544_014_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			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	02	01	H0544_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																								
H0544	015	0	1	02	01	H0544_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																								
H0544	015	0	1	02	01	H0544_015_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											114.21	25	25	25				91.37	20	20	20				20	20	20															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	70.00				35.00		35.00
H0544	015	0	1	02	01	H0544_015_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											95.46	25	25	25				95.46	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	70.00	105.00				35.00		35.00
H0544	015	0	1	02	01	H0544_015_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	015	0	1	02	01	H0544_015_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	02	01	H0544_019_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, Select Care Drugs																								
H0544	019	0	1	02	01	H0544_019_0	5			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	019	0	1	02	01	H0544_019_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					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			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
H0544	019	0	1	02	01	H0544_019_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											81.33	25	25	25				81.33	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		35.00
H0544	019	0	1	02	01	H0544_019_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																								
H0544	019	0	1	02	01	H0544_019_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			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	02	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	02	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								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	020	0	1	02	01	H0544_020_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											120.94	25	25	25				96.76	20	20	20				20	20	20															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	70.00				35.00		35.00
H0544	020	0	1	02	01	H0544_020_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											107.27	25	25	25				107.27	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		35.00
H0544	020	0	1	02	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	02	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	056	0	1	02	01	H0544_056_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	056	0	1	02	01	H0544_056_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	056	0	1	02	01	H0544_056_0	6			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					25.00	50.00	75.00					25.00	75.00	75.00																30.00				30.00			1.00	0.83	0.83			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										25.00	50.00	75.00	25.00	50.00	75.00	25.00	50.00	75.00				25.00		25.00
H0544	056	0	1	02	01	H0544_056_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											51.38	35	35	35				51.38	35	35	35				35	35	35															35			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
H0544	056	0	1	02	01	H0544_056_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	056	0	1	02	01	H0544_056_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																								
H0544	058	0	1	02	01	H0544_058_0	6			Preferred Generic	4	11	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	02	01	H0544_058_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																								
H0544	058	0	1	02	01	H0544_058_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.57	20	20	20				54.43	15	15	15				15	15	15															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	70.00				35.00		35.00
H0544	058	0	1	02	01	H0544_058_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											75.71	35	35	35				75.71	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		35.00
H0544	058	0	1	02	01	H0544_058_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																								
H0544	061	0	1	02	01	H0544_061_0	6			Preferred Generic	4	11	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	02	01	H0544_061_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H0544	061	0	1	02	01	H0544_061_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.20	20	20	20				75.20	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
H0544	061	0	1	02	01	H0544_061_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											71.82	35	35	35				71.82	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		35.00
H0544	061	0	1	02	01	H0544_061_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																								
H0544	062	0	1	02	01	H0544_062_0	6			Preferred Generic	4	11	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	02	01	H0544_062_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																								
H0544	062	0	1	02	01	H0544_062_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.36	25	25	25				67.48	20	20	20				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	70.00				35.00		35.00
H0544	062	0	1	02	01	H0544_062_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											50.64	35	35	35				50.64	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		35.00
H0544	062	0	1	02	01	H0544_062_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																								
H0544	063	0	1	02	01	H0544_063_0	6			Preferred Generic	4	11	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	02	01	H0544_063_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																								
H0544	063	0	1	02	01	H0544_063_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											87.00	25	25	25				69.60	20	20	20				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		35.00
H0544	063	0	1	02	01	H0544_063_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											74.32	40	40	40				74.32	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
H0544	063	0	1	02	01	H0544_063_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																								
H0544	064	0	1	02	01	H0544_064_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	064	0	1	02	01	H0544_064_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																								
H0544	064	0	1	02	01	H0544_064_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											40.62	20	20	20				40.62	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		35.00
H0544	064	0	1	02	01	H0544_064_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											47.84	35	35	35				47.84	35	35	35				35	35	35															35			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
H0544	064	0	1	02	01	H0544_064_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	064	0	1	02	01	H0544_064_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																								
H0544	065	0	1	02	01	H0544_065_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	065	0	1	02	01	H0544_065_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	065	0	1	02	01	H0544_065_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											73.40	25	25	25				58.72	20	20	20				20	20	20															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		35.00
H0544	065	0	1	02	01	H0544_065_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											75.51	35	35	35				75.51	35	35	35				35	35	35															35			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
H0544	065	0	1	02	01	H0544_065_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	065	0	1	02	01	H0544_065_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																								
H0544	066	0	1	02	01	H0544_066_0	6			Preferred Generic	4	11	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	02	01	H0544_066_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																								
H0544	066	0	1	02	01	H0544_066_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											66.88	20	20	20				50.16	15	15	15				15	15	15															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	70.00				35.00		35.00
H0544	066	0	1	02	01	H0544_066_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											59.16	35	35	35				59.16	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		35.00
H0544	066	0	1	02	01	H0544_066_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																								
H0544	069	0	1	02	01	H0544_069_0	6			Preferred Generic	4	11	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	02	01	H0544_069_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																								
H0544	069	0	1	02	01	H0544_069_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											95.18	25	25	25				76.14	20	20	20				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	70.00				35.00		35.00
H0544	069	0	1	02	01	H0544_069_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											80.81	35	35	35				80.81	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		35.00
H0544	069	0	1	02	01	H0544_069_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																								
H0544	091	0	1	02	01	H0544_091_0	6			Preferred Generic	4	11	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	02	01	H0544_091_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H0544	091	0	1	02	01	H0544_091_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.48	20	20	20				75.48	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	70.00				35.00		35.00
H0544	091	0	1	02	01	H0544_091_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											71.57	35	35	35				71.57	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		35.00
H0544	091	0	1	02	01	H0544_091_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																								
H0544	095	0	1	02	01	H0544_095_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	095	0	1	02	01	H0544_095_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H0544	095	0	1	02	01	H0544_095_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											41.26	20	20	20				41.26	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		35.00
H0544	095	0	1	02	01	H0544_095_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											44.76	35	35	35				44.76	35	35	35				35	35	35															35			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
H0544	095	0	1	02	01	H0544_095_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	095	0	1	02	01	H0544_095_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																								
H0544	096	0	1	02	01	H0544_096_0	6			Preferred Generic	4	11	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	02	01	H0544_096_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					6.00	12.00	18.00					0.00	0.00	0.00																12.00				12.00			0.40	0.20	0.00			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0544	096	0	1	02	01	H0544_096_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											98.93	25	25	25				79.14	20	20	20				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	70.00				35.00		35.00
H0544	096	0	1	02	01	H0544_096_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											64.12	35	35	35				64.12	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		35.00
H0544	096	0	1	02	01	H0544_096_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																								
H0544	098	0	1	02	01	H0544_098_0	6			Preferred Generic	4	11	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	02	01	H0544_098_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																								
H0544	098	0	1	02	01	H0544_098_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											83.31	20	20	20				62.49	15	15	15				15	15	15															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	70.00				35.00		35.00
H0544	098	0	1	02	01	H0544_098_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											55.00	30	30	30				55.00	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	105.00				35.00		35.00
H0544	098	0	1	02	01	H0544_098_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																								
H0544	108	0	1	02	01	H0544_108_0	6			Preferred Generic	4	11	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	02	01	H0544_108_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H0544	108	0	1	02	01	H0544_108_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											103.26	25	25	25				82.61	20	20	20				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	70.00				35.00		35.00
H0544	108	0	1	02	01	H0544_108_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											70.05	35	35	35				70.05	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		35.00
H0544	108	0	1	02	01	H0544_108_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																								
H0562	009	0	1	01	01	H0562_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			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	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	009	0	1	01	01	H0562_009_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											142.19	25	25	25				142.19	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
H0562	009	0	1	01	01	H0562_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											88.68	50	50	50				88.68	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	009	0	1	01	01	H0562_009_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, Select Care Drugs																								
H0562	009	0	1	01	01	H0562_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																								
H0562	012	0	1	01	01	H0562_012_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																								
H0562	012	0	1	01	01	H0562_012_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.73	25	25	25				156.73	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
H0562	012	0	1	01	01	H0562_012_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											90.01	38	38	38				90.01	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
H0562	012	0	1	01	01	H0562_012_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, Select Care Drugs																								
H0562	012	0	1	01	01	H0562_012_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																								
H0562	039	0	1	01	01	H0562_039_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																								
H0562	039	0	1	01	01	H0562_039_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	039	0	1	01	01	H0562_039_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											142.98	25	25	25				142.98	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
H0562	039	0	1	01	01	H0562_039_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											43.46	39	39	39				43.46	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	039	0	1	01	01	H0562_039_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, Select Care Drugs																								
H0562	039	0	1	01	01	H0562_039_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																								
H0562	079	0	1	01	01	H0562_079_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																								
H0562	079	0	1	01	01	H0562_079_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.20	25	25	25				154.20	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											64.68	44	44	44				64.68	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
H0562	079	0	1	01	01	H0562_079_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, Select Care Drugs																								
H0562	079	0	1	01	01	H0562_079_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																								
H0562	092	0	1	01	01	H0562_092_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																								
H0562	092	0	1	01	01	H0562_092_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																								
H0562	092	0	1	01	01	H0562_092_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											172.94	25	25	25				172.94	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
H0562	092	0	1	01	01	H0562_092_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											61.57	41	41	41				61.57	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	092	0	1	01	01	H0562_092_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																								
H0562	092	0	1	01	01	H0562_092_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										0.00	0.00	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	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																								
H0562	097	0	1	01	01	H0562_097_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											147.41	25	25	25				147.41	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
H0562	097	0	1	01	01	H0562_097_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											97.87	38	38	38				97.87	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
H0562	097	0	1	01	01	H0562_097_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, Select Care Drugs																								
H0562	097	0	1	01	01	H0562_097_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																								
H0562	125	0	1	01	01	H0562_125_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																								
H0562	125	0	1	01	01	H0562_125_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	125	0	1	01	01	H0562_125_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											150.81	25	25	25				150.81	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
H0562	125	0	1	01	01	H0562_125_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											83.62	33	33	33				81.09	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	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, Select Care Drugs																								
H0562	125	0	1	01	01	H0562_125_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																								
H0562	126	0	1	01	01	H0562_126_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																								
H0562	126	0	1	01	01	H0562_126_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	126	0	1	01	01	H0562_126_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											147.64	25	25	25				106.30	18	18	18										25	25	25				18	18	18			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
H0562	126	0	1	01	01	H0562_126_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											47.28	40	40	40				37.82	32	32	32										40	40	40				32	32	32			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
H0562	126	0	1	01	01	H0562_126_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, Select Care Drugs																								
H0562	126	0	1	01	01	H0562_126_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																								
H0562	133	0	1	01	01	H0562_133_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																								
H0562	133	0	1	01	01	H0562_133_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	133	0	1	01	01	H0562_133_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											152.19	25	25	25				152.19	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
H0562	133	0	1	01	01	H0562_133_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											39.60	35	35	35				39.60	35	35	35										35	35	35				35	35	35			35			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
H0562	133	0	1	01	01	H0562_133_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, Select Care Drugs																								
H0562	133	0	1	01	01	H0562_133_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																								
H0562	136	0	1	01	01	H0562_136_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																								
H0562	136	0	1	01	01	H0562_136_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																								
H0562	136	0	1	01	01	H0562_136_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											143.85	25	25	25				143.85	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
H0562	136	0	1	01	01	H0562_136_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											72.22	36	36	36				70.21	35	35	35										36	36	36				35	35	35			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
H0562	136	0	1	01	01	H0562_136_0	7			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																								
H0562	136	0	1	01	01	H0562_136_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																								
H0562	137	0	1	01	01	H0562_137_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																								
H0562	137	0	1	01	01	H0562_137_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	137	0	1	01	01	H0562_137_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											149.46	25	25	25				149.46	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	137	0	1	01	01	H0562_137_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											44.56	36	36	36				44.56	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
H0562	137	0	1	01	01	H0562_137_0	8			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																								
H0562	137	0	1	01	01	H0562_137_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																								
H0571	001	0	1	01	01	H0571_001_0	11			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	11			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	11			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	11			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										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0571	001	0	1	01	01	H0571_001_0	11			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											930.05	33						336.04	33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0571	007	0	1	01	01	H0571_007_0	10			Preferred Generic	4	01	1	2	1	1		111	10	100		1				30	60	90	1	2			90					14	31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																	0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0571	007	0	1	01	01	H0571_007_0	10			Generic	4	01	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								3.00	6.00	6.00					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										3.00	6.00	6.00	0.00	0.00	0.00			0.00				3.00		3.00
H0571	007	0	1	01	01	H0571_007_0	10			Preferred Brand	4	11	1	2	3	1		111	10	100		1				30	60	90	1	2			90					14	31								35.00	70.00	105.00					35.00	70.00	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			70.00				35.00		35.00
H0571	007	0	1	01	01	H0571_007_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10	100		1				30	60	90	1	2			90					14	31								75.00	150.00	225.00					75.00	150.00	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	105.00			105.00				35.00		35.00
H0571	007	0	1	01	01	H0571_007_0	10			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											755.48	30						295.06	30						30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0571	010	0	1	01	01	H0571_010_0	10			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	010	0	1	01	01	H0571_010_0	10			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	010	0	1	01	01	H0571_010_0	10			Preferred Brand	4	11	1	2	3	1		111	10	100		1				30	60	90	1	2			90					14	31								30.00	60.00	90.00					30.00	60.00	60.00							60.00																	30.00			30.00			1.00	1.00				0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00	60.00	90.00	30.00	60.00	60.00			60.00				30.00		30.00
H0571	010	0	1	01	01	H0571_010_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10	100		1				30	60	90	1	2			90					14	31								50.00	100.00	150.00					50.00	100.00	100.00							100.00																	50.00			50.00			1.67	1.67				1.61	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
H0571	010	0	1	01	01	H0571_010_0	10			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											864.36	30						61.54	30						30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0571	011	0	1	01	01	H0571_011_0	10			Preferred Generic	4	01	1	2	1	1		111	10	100		1				30	60	90	1	2			90					14	31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																	0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0571	011	0	1	01	01	H0571_011_0	10			Generic	4	01	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								3.00	6.00	6.00					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										3.00	6.00	6.00	0.00	0.00	0.00			0.00				3.00		3.00
H0571	011	0	1	01	01	H0571_011_0	10			Preferred Brand	4	11	1	2	3	1		111	10	100		1				30	60	90	1	2			90					14	31								35.00	70.00	105.00					35.00	70.00	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			70.00				35.00		35.00
H0571	011	0	1	01	01	H0571_011_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10	100		1				30	60	90	1	2			90					14	31								75.00	150.00	225.00					75.00	150.00	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	105.00			105.00				35.00		35.00
H0571	011	0	1	01	01	H0571_011_0	10			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											890.31	30						63.10	30						30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0609	007	0	1	02	01	H0609_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																								
H0609	007	0	1	02	01	H0609_007_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																								
H0609	007	0	1	02	01	H0609_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
H0609	007	0	1	02	01	H0609_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	007	0	1	02	01	H0609_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H0609	012	0	1	02	01	H0609_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																								
H0609	012	0	1	02	01	H0609_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																								
H0609	012	0	1	02	01	H0609_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
H0609	012	0	1	02	01	H0609_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	012	0	1	02	01	H0609_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				192.00	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
H0609	025	0	1	02	01	H0609_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																								
H0609	025	0	1	02	01	H0609_025_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																								
H0609	025	0	1	02	01	H0609_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
H0609	025	0	1	02	01	H0609_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	025	0	1	02	01	H0609_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				199.00	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
H0609	026	0	1	02	01	H0609_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																								
H0609	026	0	1	02	01	H0609_026_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																								
H0609	026	0	1	02	01	H0609_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
H0609	026	0	1	02	01	H0609_026_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	026	0	1	02	01	H0609_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				210.00	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
H0609	027	0	1	02	01	H0609_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																								
H0609	027	0	1	02	01	H0609_027_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																								
H0609	027	0	1	02	01	H0609_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
H0609	027	0	1	02	01	H0609_027_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	027	0	1	02	01	H0609_027_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				205.00	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
H0609	028	0	1	02	01	H0609_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																								
H0609	028	0	1	02	01	H0609_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																								
H0609	028	0	1	02	01	H0609_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
H0609	028	0	1	02	01	H0609_028_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	028	0	1	02	01	H0609_028_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				178.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				220.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				185.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				191.00	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
H0609	034	1	1	02	01	H0609_034_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																								
H0609	034	1	1	02	01	H0609_034_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																								
H0609	034	1	1	02	01	H0609_034_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
H0609	034	1	1	02	01	H0609_034_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	034	1	1	02	01	H0609_034_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H0609	034	2	1	02	01	H0609_034_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																								
H0609	034	2	1	02	01	H0609_034_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																								
H0609	034	2	1	02	01	H0609_034_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
H0609	034	2	1	02	01	H0609_034_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	034	2	1	02	01	H0609_034_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H0609	036	1	1	02	01	H0609_036_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																								
H0609	036	1	1	02	01	H0609_036_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																								
H0609	036	1	1	02	01	H0609_036_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
H0609	036	1	1	02	01	H0609_036_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	036	1	1	02	01	H0609_036_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H0609	036	2	1	02	01	H0609_036_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																								
H0609	036	2	1	02	01	H0609_036_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																								
H0609	036	2	1	02	01	H0609_036_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
H0609	036	2	1	02	01	H0609_036_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	036	2	1	02	01	H0609_036_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				167.00	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
H0609	038	0	1	02	01	H0609_038_0	9			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	9			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	9			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		141.00													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		105.00			105.00			95.00	35.00		35.00
H0609	038	0	1	02	01	H0609_038_0	9			Non-Preferred Drug	4	11	1	2	4	1		010	01		010	1				30			2	2				30			30		31								100.00							100.00													100.00						100.00						100.00				100.00			3.33	3.33		3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
H0609	038	0	1	02	01	H0609_038_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											141.00	31						210.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				211.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	042	0	1	02	01	H0609_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				150.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	043	0	1	02	01	H0609_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				172.00	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
H0609	044	0	1	02	01	H0609_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																								
H0609	044	0	1	02	01	H0609_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																								
H0609	044	0	1	02	01	H0609_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
H0609	044	0	1	02	01	H0609_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	044	0	1	02	01	H0609_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				217.00	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
H0609	045	0	1	02	01	H0609_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																								
H0609	045	0	1	02	01	H0609_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																								
H0609	045	0	1	02	01	H0609_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
H0609	045	0	1	02	01	H0609_045_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	045	0	1	02	01	H0609_045_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H0609	046	0	1	02	01	H0609_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																								
H0609	046	0	1	02	01	H0609_046_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																								
H0609	046	0	1	02	01	H0609_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
H0609	046	0	1	02	01	H0609_046_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	046	0	1	02	01	H0609_046_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				192.00	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
H0609	048	0	1	02	01	H0609_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																								
H0609	048	0	1	02	01	H0609_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																								
H0609	048	0	1	02	01	H0609_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
H0609	048	0	1	02	01	H0609_048_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	048	0	1	02	01	H0609_048_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				169.00	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
H0609	050	0	1	02	01	H0609_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																								
H0609	050	0	1	02	01	H0609_050_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																								
H0609	050	0	1	02	01	H0609_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
H0609	050	0	1	02	01	H0609_050_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	050	0	1	02	01	H0609_050_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				224.00	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
H0609	051	0	1	02	01	H0609_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																								
H0609	051	0	1	02	01	H0609_051_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																								
H0609	051	0	1	02	01	H0609_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
H0609	051	0	1	02	01	H0609_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	051	0	1	02	01	H0609_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				191.00	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
H0609	054	0	1	02	01	H0609_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																								
H0609	054	0	1	02	01	H0609_054_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																								
H0609	054	0	1	02	01	H0609_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
H0609	054	0	1	02	01	H0609_054_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	054	0	1	02	01	H0609_054_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				170.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				211.00	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
H0609	059	0	1	02	01	H0609_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																								
H0609	059	0	1	02	01	H0609_059_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																								
H0609	059	0	1	02	01	H0609_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
H0609	059	0	1	02	01	H0609_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	059	0	1	02	01	H0609_059_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				199.00	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
H0609	060	0	1	02	01	H0609_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																								
H0609	060	0	1	02	01	H0609_060_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																								
H0609	060	0	1	02	01	H0609_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
H0609	060	0	1	02	01	H0609_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	060	0	1	02	01	H0609_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				191.00	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
H0609	061	0	1	02	01	H0609_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																								
H0609	061	0	1	02	01	H0609_061_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																								
H0609	061	0	1	02	01	H0609_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
H0609	061	0	1	02	01	H0609_061_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	061	0	1	02	01	H0609_061_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				193.00	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
H0609	062	0	1	02	01	H0609_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																								
H0609	062	0	1	02	01	H0609_062_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																								
H0609	062	0	1	02	01	H0609_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										25.00		75.00						75.00			65.00	25.00		25.00
H0609	062	0	1	02	01	H0609_062_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	062	0	1	02	01	H0609_062_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				218.00	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
H0609	066	0	1	02	01	H0609_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																								
H0609	066	0	1	02	01	H0609_066_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																								
H0609	066	0	1	02	01	H0609_066_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
H0609	066	0	1	02	01	H0609_066_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	066	0	1	02	01	H0609_066_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				188.00	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
H0609	067	0	1	02	01	H0609_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																								
H0609	067	0	1	02	01	H0609_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																								
H0609	067	0	1	02	01	H0609_067_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
H0609	067	0	1	02	01	H0609_067_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	067	0	1	02	01	H0609_067_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				222.00	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
H0609	068	0	1	02	01	H0609_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																								
H0609	068	0	1	02	01	H0609_068_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																								
H0609	068	0	1	02	01	H0609_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
H0609	068	0	1	02	01	H0609_068_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	068	0	1	02	01	H0609_068_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				177.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				194.00	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
H0609	072	0	1	02	01	H0609_072_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	072	0	1	02	01	H0609_072_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	072	0	1	02	01	H0609_072_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	072	0	1	02	01	H0609_072_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	072	0	1	02	01	H0609_072_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				193.00	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
H0609	073	0	1	02	01	H0609_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																								
H0609	073	0	1	02	01	H0609_073_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																								
H0609	073	0	1	02	01	H0609_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
H0609	073	0	1	02	01	H0609_073_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	073	0	1	02	01	H0609_073_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
H0609	075	0	1	02	01	H0609_075_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																								
H0609	075	0	1	02	01	H0609_075_0	5			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.50	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0609	075	0	1	02	01	H0609_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					47.00		141.00													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		105.00			105.00			95.00	35.00		35.00
H0609	075	0	1	02	01	H0609_075_0	5			Non-Preferred Drug	4	11	1	2	4	1		010	01		010	1				30			2	2				30			30		31								100.00							100.00													100.00						100.00						100.00				100.00			3.33	3.33		3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
H0609	075	0	1	02	01	H0609_075_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											134.00	30						206.00	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
H0609	077	0	1	02	01	H0609_077_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	077	0	1	02	01	H0609_077_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																								
H0609	077	0	1	02	01	H0609_077_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
H0609	077	0	1	02	01	H0609_077_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	077	0	1	02	01	H0609_077_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				181.00	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
H0609	078	0	1	02	01	H0609_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																								
H0609	078	0	1	02	01	H0609_078_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																								
H0609	078	0	1	02	01	H0609_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
H0609	078	0	1	02	01	H0609_078_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0609	078	0	1	02	01	H0609_078_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				214.00	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
H0628	001	0	1	02	01	H0628_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	001	0	1	02	01	H0628_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	001	0	1	02	01	H0628_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.27	25	25	25				97.20	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
H0628	001	0	1	02	01	H0628_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.78	35	35	35				29.16	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
H0628	001	0	1	02	01	H0628_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1217.90	33						1074.85	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
H0628	003	0	1	02	01	H0628_003_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	003	0	1	02	01	H0628_003_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	003	0	1	02	01	H0628_003_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.58	24	24	24				111.01	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
H0628	003	0	1	02	01	H0628_003_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.08	25	25	25				33.03	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
H0628	003	0	1	02	01	H0628_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.32	25						890.39	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
H0628	005	0	1	02	01	H0628_005_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	005	0	1	02	01	H0628_005_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	005	0	1	02	01	H0628_005_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.85	25	25	25				94.11	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
H0628	005	0	1	02	01	H0628_005_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.13	35	35	35				25.93	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
H0628	005	0	1	02	01	H0628_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1269.61	33						972.26	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
H0628	007	0	1	02	01	H0628_007_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	007	0	1	02	01	H0628_007_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	007	0	1	02	01	H0628_007_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.13	25	25	25				82.23	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
H0628	007	0	1	02	01	H0628_007_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.34	35	35	35				30.25	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
H0628	007	0	1	02	01	H0628_007_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1075.74	33						891.27	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
H0628	008	0	1	02	01	H0628_008_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	008	0	1	02	01	H0628_008_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	008	0	1	02	01	H0628_008_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.32	25	25	25				84.42	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
H0628	008	0	1	02	01	H0628_008_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.84	35	35	35				28.93	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
H0628	008	0	1	02	01	H0628_008_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											991.04	33						1084.43	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
H0628	010	0	1	02	01	H0628_010_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	010	0	1	02	01	H0628_010_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	010	0	1	02	01	H0628_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											64.34	25	25	25				80.84	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
H0628	010	0	1	02	01	H0628_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											39.02	35	35	35				28.85	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
H0628	010	0	1	02	01	H0628_010_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1079.66	33						968.29	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
H0628	017	0	1	02	01	H0628_017_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	017	0	1	02	01	H0628_017_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	017	0	1	02	01	H0628_017_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.83	25	25	25				90.67	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
H0628	017	0	1	02	01	H0628_017_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.34	35	35	35				27.83	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
H0628	017	0	1	02	01	H0628_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											935.71	33						936.29	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
H0628	019	0	1	02	01	H0628_019_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	019	0	1	02	01	H0628_019_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	019	0	1	02	01	H0628_019_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.82	24	24	24				109.00	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
H0628	019	0	1	02	01	H0628_019_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.14	25	25	25				35.60	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
H0628	019	0	1	02	01	H0628_019_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											886.92	25						814.20	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
H0628	021	0	1	02	01	H0628_021_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	021	0	1	02	01	H0628_021_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	021	0	1	02	01	H0628_021_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.75	25	25	25				106.19	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
H0628	021	0	1	02	01	H0628_021_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.66	26	26	26				35.30	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	021	0	1	02	01	H0628_021_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1055.38	30						981.79	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
H0628	023	0	1	02	01	H0628_023_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	023	0	1	02	01	H0628_023_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	023	0	1	02	01	H0628_023_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.15	25	25	25				101.46	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
H0628	023	0	1	02	01	H0628_023_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.38	26	26	26				33.76	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	023	0	1	02	01	H0628_023_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1006.41	30						942.68	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
H0628	024	0	1	02	01	H0628_024_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	024	0	1	02	01	H0628_024_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0628	024	0	1	02	01	H0628_024_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.15	25	25	25				101.46	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
H0628	024	0	1	02	01	H0628_024_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.38	26	26	26				33.76	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	024	0	1	02	01	H0628_024_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1006.41	30						942.42	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
H0628	027	0	1	02	01	H0628_027_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	027	0	1	02	01	H0628_027_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H0628	027	0	1	02	01	H0628_027_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.18	22	22	22				41.69	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	027	0	1	02	01	H0628_027_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.97	25	25	25				44.08	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
H0628	027	0	1	02	01	H0628_027_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											359.34	25						316.22	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
H0630	013	0	1	01	01	H0630_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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	013	0	1	01	01	H0630_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					3.00	6.00	9.00					0.00	0.00	0.00																20.00				3.00			0.66	0.10	0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	3.00	6.00	9.00	0.00	0.00	0.00				20.00		3.00
H0630	013	0	1	01	01	H0630_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					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H0630	014	0	1	01	01	H0630_014_0	10		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				1.00	22	22	22																		22	22	22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	014	0	1	01	01	H0630_014_0	10		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				7.00	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	014	0	1	01	01	H0630_014_0	10		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				84.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	014	0	1	01	01	H0630_014_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				116.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	014	0	1	01	01	H0630_014_0	10		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				824.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	014	0	1	01	01	H0630_014_0	10		N	Vaccines	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																								
H0630	015	0	1	02	01	H0630_015_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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	015	0	1	02	01	H0630_015_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					0.00	0.00	0.00					0.00	0.00	0.00																20.00				0.00			0.66	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		0.00
H0630	015	0	1	02	01	H0630_015_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H0630	016	0	1	02	01	H0630_016_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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	016	0	1	02	01	H0630_016_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					0.00	0.00	0.00					0.00	0.00	0.00																20.00				0.00			0.66	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		0.00
H0630	016	0	1	02	01	H0630_016_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H0630	017	0	1	01	01	H0630_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								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										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	017	0	1	01	01	H0630_017_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				5.00			0.66	0.16	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		5.00
H0630	017	0	1	01	01	H0630_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					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H0630	020	0	1	01	01	H0630_020_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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	020	0	1	01	01	H0630_020_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					3.00	6.00	9.00					0.00	0.00	0.00																20.00				3.00			0.66	0.10	0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	3.00	6.00	9.00	0.00	0.00	0.00				20.00		3.00
H0630	020	0	1	01	01	H0630_020_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H0630	021	0	1	02	01	H0630_021_0	9			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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	021	0	1	02	01	H0630_021_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					0.00	0.00	0.00					0.00	0.00	0.00																20.00				0.00			0.66	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		0.00
H0630	021	0	1	02	01	H0630_021_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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					90.00	180.00	270.00					90.00	180.00	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	9			Vaccines	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																								
H0630	023	0	1	02	01	H0630_023_0	9			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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	023	0	1	02	01	H0630_023_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					5.00	10.00	15.00					0.00	0.00	0.00																20.00				5.00			0.66	0.16	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		5.00
H0630	023	0	1	02	01	H0630_023_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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					90.00	180.00	270.00					90.00	180.00	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	9			Vaccines	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																								
H0630	024	0	1	01	01	H0630_024_0	10		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				2.00	22	22	22																		22	22	22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H0630	024	0	1	01	01	H0630_024_0	10		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				8.00	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0630	024	0	1	01	01	H0630_024_0	10		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				90.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0630	024	0	1	01	01	H0630_024_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				127.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0630	024	0	1	01	01	H0630_024_0	10		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				789.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0630	024	0	1	01	01	H0630_024_0	10		N	Vaccines	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																								
H0630	025	0	1	02	01	H0630_025_0	9			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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	025	0	1	02	01	H0630_025_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					3.00	6.00	9.00					0.00	0.00	0.00																20.00				3.00			0.66	0.10	0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	3.00	6.00	9.00	0.00	0.00	0.00				20.00		3.00
H0630	025	0	1	02	01	H0630_025_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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					90.00	180.00	270.00					90.00	180.00	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	9			Vaccines	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																								
H0630	026	0	1	02	01	H0630_026_0	9			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				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0630	026	0	1	02	01	H0630_026_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					5.00	10.00	15.00					0.00	0.00	0.00																20.00				5.00			0.66	0.16	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		5.00
H0630	026	0	1	02	01	H0630_026_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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					90.00	180.00	270.00					90.00	180.00	270.00																100.00				90.00			3.33	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	9			Vaccines	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																								
H0630	027	0	1	01	01	H0630_027_0	11		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	027	0	1	01	01	H0630_027_0	11		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				7.00	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	027	0	1	01	01	H0630_027_0	11		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				79.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	027	0	1	01	01	H0630_027_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				114.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	027	0	1	01	01	H0630_027_0	11		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				769.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0630	027	0	1	01	01	H0630_027_0	11		N	Vaccines	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																								
H0672	001	0	1	01	01	H0672_001_0	5			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	5			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	5			Preferred Brand	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
H0672	001	0	1	01	01	H0672_001_0	5			Non-Preferred Drug	4	11	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
H0672	001	0	1	01	01	H0672_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											920.27	33						673.57	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
H0672	003	0	1	01	01	H0672_003_0	4			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	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					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	4			Preferred Brand	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
H0672	003	0	1	01	01	H0672_003_0	4			Non-Preferred Drug	4	11	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
H0672	003	0	1	01	01	H0672_003_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											772.48	33						751.03	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
H0672	004	0	1	01	01	H0672_004_0	4			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	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					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	4			Preferred Brand	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
H0672	004	0	1	01	01	H0672_004_0	4			Non-Preferred Drug	4	11	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
H0672	004	0	1	01	01	H0672_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											872.52	33						791.97	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
H0672	005	0	1	01	01	H0672_005_0	4			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	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	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	4			Preferred Brand	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
H0672	005	0	1	01	01	H0672_005_0	4			Non-Preferred Drug	4	11	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
H0672	005	0	1	01	01	H0672_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											828.73	33						791.04	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
H0672	006	0	1	01	01	H0672_006_0	4			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	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	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	006	0	1	01	01	H0672_006_0	4			Preferred Brand	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
H0672	006	0	1	01	01	H0672_006_0	4			Non-Preferred Drug	4	11	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
H0672	006	0	1	01	01	H0672_006_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											920.34	33						456.31	33												33						33					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	4			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	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					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	4			Preferred Brand	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
H0672	008	0	1	01	01	H0672_008_0	4			Non-Preferred Drug	4	11	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
H0672	008	0	1	01	01	H0672_008_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											777.42	33						655.51	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
H0672	011	0	1	01	01	H0672_011_0	4			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	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	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	011	0	1	01	01	H0672_011_0	4			Preferred Brand	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
H0672	011	0	1	01	01	H0672_011_0	4			Non-Preferred Drug	4	11	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
H0672	011	0	1	01	01	H0672_011_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											957.02	33						759.22	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
H0672	013	0	1	01	01	H0672_013_0	4			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	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	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	013	0	1	01	01	H0672_013_0	4			Preferred Brand	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
H0672	013	0	1	01	01	H0672_013_0	4			Non-Preferred Drug	4	11	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
H0672	013	0	1	01	01	H0672_013_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											768.49	33						607.45	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
H0672	014	0	1	01	01	H0672_014_0	4			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	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	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	014	0	1	01	01	H0672_014_0	4			Preferred Brand	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
H0672	014	0	1	01	01	H0672_014_0	4			Non-Preferred Drug	4	11	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
H0672	014	0	1	01	01	H0672_014_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											951.06	33						756.20	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
H0672	016	0	1	01	01	H0672_016_0	4			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	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	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	016	0	1	01	01	H0672_016_0	4			Preferred Brand	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
H0672	016	0	1	01	01	H0672_016_0	4			Non-Preferred Drug	4	11	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
H0672	016	0	1	01	01	H0672_016_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											790.65	33						575.51	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
H0672	017	0	1	01	01	H0672_017_0	4			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	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	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	017	0	1	01	01	H0672_017_0	4			Preferred Brand	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
H0672	017	0	1	01	01	H0672_017_0	4			Non-Preferred Drug	4	11	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
H0672	017	0	1	01	01	H0672_017_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											825.68	33						703.62	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
H0672	019	0	1	02	01	H0672_019_0	4			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	019	0	1	02	01	H0672_019_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					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	019	0	1	02	01	H0672_019_0	4			Preferred Brand	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
H0672	019	0	1	02	01	H0672_019_0	4			Non-Preferred Drug	4	11	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
H0672	019	0	1	02	01	H0672_019_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											772.95	33						699.94	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
H0672	020	0	1	02	01	H0672_020_0	4			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	020	0	1	02	01	H0672_020_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					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	020	0	1	02	01	H0672_020_0	4			Preferred Brand	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
H0672	020	0	1	02	01	H0672_020_0	4			Non-Preferred Drug	4	11	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
H0672	020	0	1	02	01	H0672_020_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											772.95	33						699.94	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
H0672	021	0	1	02	01	H0672_021_0	4			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	021	0	1	02	01	H0672_021_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					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	021	0	1	02	01	H0672_021_0	4			Preferred Brand	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
H0672	021	0	1	02	01	H0672_021_0	4			Non-Preferred Drug	4	11	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
H0672	021	0	1	02	01	H0672_021_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											772.95	33						699.94	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
H0672	022	0	1	02	01	H0672_022_0	4			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	022	0	1	02	01	H0672_022_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					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	022	0	1	02	01	H0672_022_0	4			Preferred Brand	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
H0672	022	0	1	02	01	H0672_022_0	4			Non-Preferred Drug	4	11	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
H0672	022	0	1	02	01	H0672_022_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											772.95	33						699.94	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
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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				157.00	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
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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				167.00	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
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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				147.00	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
H0712	019	0	1	02	01	H0712_019_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																								
H0712	019	0	1	02	01	H0712_019_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0712	019	0	1	02	01	H0712_019_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											148.36	25	25	25				148.36	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
H0712	019	0	1	02	01	H0712_019_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											73.35	42	42	42				71.60	41	41	41										42	42	42				41	41	41			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
H0712	019	0	1	02	01	H0712_019_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, Select Care Drugs																								
H0712	019	0	1	02	01	H0712_019_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																								
H0712	032	0	1	02	01	H0712_032_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																								
H0712	032	0	1	02	01	H0712_032_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H0712	032	0	1	02	01	H0712_032_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.49	25	25	25				164.49	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
H0712	032	0	1	02	01	H0712_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											54.84	31	31	31				53.07	30	30	30										31	31	31				30	30	30			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
H0712	032	0	1	02	01	H0712_032_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, Select Care Drugs																								
H0712	032	0	1	02	01	H0712_032_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																								
H0755	030	0	1	02	01	H0755_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																								
H0755	030	0	1	02	01	H0755_030_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																								
H0755	030	0	1	02	01	H0755_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
H0755	030	0	1	02	01	H0755_030_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0755	030	0	1	02	01	H0755_030_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H0755	031	0	1	02	01	H0755_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																								
H0755	031	0	1	02	01	H0755_031_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	031	0	1	02	01	H0755_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
H0755	031	0	1	02	01	H0755_031_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0755	031	0	1	02	01	H0755_031_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
H0755	033	0	1	02	01	H0755_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																								
H0755	033	0	1	02	01	H0755_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																								
H0755	033	0	1	02	01	H0755_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
H0755	033	0	1	02	01	H0755_033_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0755	033	0	1	02	01	H0755_033_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H0755	038	0	1	02	01	H0755_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																								
H0755	038	0	1	02	01	H0755_038_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																								
H0755	038	0	1	02	01	H0755_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
H0755	038	0	1	02	01	H0755_038_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0755	038	0	1	02	01	H0755_038_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				179.00	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
H0755	045	0	1	02	01	H0755_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																								
H0755	045	0	1	02	01	H0755_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																								
H0755	045	0	1	02	01	H0755_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
H0755	045	0	1	02	01	H0755_045_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H0755	045	0	1	02	01	H0755_045_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				197.00	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
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	0.00		0.00																									20.00		60.00				0.00		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
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	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H0783	002	0	1	01	01	H0783_002_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	30		30																								30		30				30		30			30			30								Preferred Generic, 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					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
H0783	003	0	1	01	01	H0783_003_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
H0783	003	0	1	01	01	H0783_003_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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
H0783	003	0	1	01	01	H0783_003_0	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		95.00	35.00		35.00
H0783	003	0	1	01	01	H0783_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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		35.00
H0783	003	0	1	01	01	H0783_003_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
H0783	004	0	1	01	01	H0783_004_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
H0783	004	0	1	01	01	H0783_004_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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
H0783	004	0	1	01	01	H0783_004_0	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		95.00	35.00		35.00
H0783	004	0	1	01	01	H0783_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H0783	004	0	1	01	01	H0783_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
H0885	001	0	1	04	01	H0885_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	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				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
H0885	001	0	1	04	01	H0885_001_0	5			Generic	4	01	3	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				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, Select Care Drugs										10.00	20.00	30.00				10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00
H0885	001	0	1	04	01	H0885_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				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	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, 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	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, Select Care Drugs																								
H0885	001	0	1	04	01	H0885_001_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0885	002	0	1	04	01	H0885_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	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				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
H0885	002	0	1	04	01	H0885_002_0	5			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										8.00	16.00	24.00				8.00	16.00	24.00	4.00	8.00	12.00	8.00		8.00
H0885	002	0	1	04	01	H0885_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				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	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, 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	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, Select Care Drugs																								
H0885	002	0	1	04	01	H0885_002_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0885	003	0	1	04	01	H0885_003_0	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		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
H0885	003	0	1	04	01	H0885_003_0	5			Generic	4	01	3	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				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, Select Care Drugs										10.00	20.00	30.00				10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00
H0885	003	0	1	04	01	H0885_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																									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	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, 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	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, Select Care Drugs																								
H0885	003	0	1	04	01	H0885_003_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0885	005	0	1	04	01	H0885_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	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				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
H0885	005	0	1	04	01	H0885_005_0	5			Generic	4	01	3	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				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, Select Care Drugs										10.00	20.00	30.00				10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00
H0885	005	0	1	04	01	H0885_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				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	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, 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	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, Select Care Drugs																								
H0885	005	0	1	04	01	H0885_005_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0885	006	0	1	04	01	H0885_006_0	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		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
H0885	006	0	1	04	01	H0885_006_0	5			Generic	4	01	3	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				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, Select Care Drugs										10.00	20.00	30.00				10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00
H0885	006	0	1	04	01	H0885_006_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				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	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, 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	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, Select Care Drugs																								
H0885	006	0	1	04	01	H0885_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0885	007	0	1	04	01	H0885_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	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				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
H0885	007	0	1	04	01	H0885_007_0	5			Generic	4	01	3	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				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, Select Care Drugs										10.00	20.00	30.00				10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00
H0885	007	0	1	04	01	H0885_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				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	007	0	1	04	01	H0885_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				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	007	0	1	04	01	H0885_007_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, Select Care Drugs																								
H0885	007	0	1	04	01	H0885_007_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0885	008	0	1	04	01	H0885_008_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		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
H0885	008	0	1	04	01	H0885_008_0	6			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										8.00	16.00	24.00				8.00	16.00	24.00	4.00	8.00	12.00	8.00		8.00
H0885	008	0	1	04	01	H0885_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				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	008	0	1	04	01	H0885_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				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	008	0	1	04	01	H0885_008_0	6			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, Select Care Drugs																								
H0885	008	0	1	04	01	H0885_008_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0885	009	0	1	04	01	H0885_009_0	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		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
H0885	009	0	1	04	01	H0885_009_0	5			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										8.00	16.00	24.00				8.00	16.00	24.00	4.00	8.00	12.00	8.00		8.00
H0885	009	0	1	04	01	H0885_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				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	009	0	1	04	01	H0885_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				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	009	0	1	04	01	H0885_009_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, Select Care Drugs																								
H0885	009	0	1	04	01	H0885_009_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	001	0	1	02	01	H0908_001_0	5		N	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					7.00	14.00	21.00											19.00	38.00	57.00				7.00	14.00	0.00				19.00				19.00			0.63	0.23		0.63	0.23	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	001	0	1	02	01	H0908_001_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	001	0	1	02	01	H0908_001_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											127.84	22	22	22				127.84	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
H0908	001	0	1	02	01	H0908_001_0	5		N	Non-Preferred Drug	3	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	200.00				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
H0908	001	0	1	02	01	H0908_001_0	5		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, Select Care Drugs																								
H0908	001	0	1	02	01	H0908_001_0	5		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	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	02	01	H0908_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			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	02	01	H0908_003_0	5			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																								
H0908	003	0	1	02	01	H0908_003_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.90	25	25	25				161.90	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
H0908	003	0	1	02	01	H0908_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											66.32	48	48	48				66.32	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
H0908	003	0	1	02	01	H0908_003_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, Select Care Drugs																								
H0908	003	0	1	02	01	H0908_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																								
H0908	004	0	1	02	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	004	0	1	02	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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	004	0	1	02	01	H0908_004_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											134.70	22	22	22				134.70	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
H0908	004	0	1	02	01	H0908_004_0	5			Non-Preferred Drug	3	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	200.00				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
H0908	004	0	1	02	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																								
H0908	004	0	1	02	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								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																								
H0908	005	0	1	02	01	H0908_005_0	5			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	005	0	1	02	01	H0908_005_0	5			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																								
H0908	005	0	1	02	01	H0908_005_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.06	25	25	25				151.06	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
H0908	005	0	1	02	01	H0908_005_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											61.72	41	41	41				60.21	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
H0908	005	0	1	02	01	H0908_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, Select Care Drugs																								
H0908	005	0	1	02	01	H0908_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	006	0	1	02	01	H0908_006_0	5		N	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	006	0	1	02	01	H0908_006_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0908	006	0	1	02	01	H0908_006_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											133.36	21	21	21				133.36	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
H0908	006	0	1	02	01	H0908_006_0	5		N	Non-Preferred Drug	3	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	200.00				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
H0908	006	0	1	02	01	H0908_006_0	5		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, Select Care Drugs																								
H0908	006	0	1	02	01	H0908_006_0	5		N	Select Care Drugs	3	11	1	2	6	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																								
H0913	002	0	1	02	01	H0913_002_0	5			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	002	0	1	02	01	H0913_002_0	5			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																								
H0913	002	0	1	02	01	H0913_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											148.48	25	25	25				148.48	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
H0913	002	0	1	02	01	H0913_002_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											55.53	35	35	35				53.95	34	34	34										35	35	35				34	34	34			35			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
H0913	002	0	1	02	01	H0913_002_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, Select Care Drugs																								
H0913	002	0	1	02	01	H0913_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	0.00				0.00				0.00			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	4		N	Preferred Generic	3	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	8.00	0.00				4.00				4.00		0.13				0.13	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0913	013	0	1	01	01	H0913_013_0	4		N	Generic	3	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																									17.00	34.00	51.00				17.00	34.00	0.00				17.00				17.00		0.57				0.57	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0913	013	0	1	01	01	H0913_013_0	4		N	Preferred Brand	3	11	1	1	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31				103.85	19	19	19																								19	19	19				19	19	19			19			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
H0913	013	0	1	01	01	H0913_013_0	4		N	Non-Preferred Drug	3	11	1	1	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31				62.01	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		35.00
H0913	013	0	1	01	01	H0913_013_0	4		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																								
H0913	013	0	1	01	01	H0913_013_0	4		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	02	01	H0913_015_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					9.00	18.00	27.00											19.00	38.00	57.00				9.00	18.00	0.00				19.00				19.00			0.63	0.3		0.63	0.3	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0913	015	0	1	02	01	H0913_015_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H0913	015	0	1	02	01	H0913_015_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											116.78	20	20	20				116.78	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
H0913	015	0	1	02	01	H0913_015_0	5			Non-Preferred Drug	3	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	200.00				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
H0913	015	0	1	02	01	H0913_015_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																								
H0913	015	0	1	02	01	H0913_015_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								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																								
H0913	017	0	1	02	01	H0913_017_0	5			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	02	01	H0913_017_0	5			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																								
H0913	017	0	1	02	01	H0913_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.08	25	25	25				156.08	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
H0913	017	0	1	02	01	H0913_017_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											69.09	33	33	33				69.09	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	02	01	H0913_017_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, Select Care Drugs																								
H0913	017	0	1	02	01	H0913_017_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																								
H0913	021	0	1	02	01	H0913_021_0	5			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	02	01	H0913_021_0	5			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																								
H0913	021	0	1	02	01	H0913_021_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											160.25	25	25	25				160.25	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
H0913	021	0	1	02	01	H0913_021_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											59.82	32	32	32				57.95	31	31	31										32	32	32				31	31	31			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
H0913	021	0	1	02	01	H0913_021_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, Select Care Drugs																								
H0913	021	0	1	02	01	H0913_021_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																								
H0927	001	0	1	48	05	H0927_001_0	4			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	4			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	4			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															
H0976	001	0	1	01	01	H0976_001_0	8		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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0976	001	0	1	01	01	H0976_001_0	8		N	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	2.00					0.00	0.00	0.00											1.00	2.00	2.00				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																								
H0976	001	0	1	01	01	H0976_001_0	8		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.74	25	25	25				99.74	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
H0976	001	0	1	01	01	H0976_001_0	8		N	Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.18	50	50	50				90.18	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
H0976	001	0	1	01	01	H0976_001_0	8		N	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																								
H0976	002	0	1	01	01	H0976_002_0	8		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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H0976	002	0	1	01	01	H0976_002_0	8		N	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	2.00					0.00	0.00	0.00											1.00	2.00	2.00				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																								
H0976	002	0	1	01	01	H0976_002_0	8		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.00	25	25	25				88.00	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
H0976	002	0	1	01	01	H0976_002_0	8		N	Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.97	45	45	45				77.97	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
H0976	002	0	1	01	01	H0976_002_0	8		N	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																								
H0978	001	0	1	01	01	H0978_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	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																								
H0978	001	0	1	01	01	H0978_001_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																								
H0978	001	0	1	01	01	H0978_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H0978	001	0	1	01	01	H0978_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											74.01	50	50	50				74.01	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
H0978	001	0	1	01	01	H0978_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																								
H0978	002	0	1	01	01	H0978_002_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																								
H0978	002	0	1	01	01	H0978_002_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																								
H0978	002	0	1	01	01	H0978_002_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	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										0.00	0.00	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.77	50	50	50				88.77	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
H0978	002	0	1	01	01	H0978_002_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																								
H0978	009	0	1	01	01	H0978_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								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																								
H0978	009	0	1	01	01	H0978_009_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																								
H0978	009	0	1	01	01	H0978_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H0978	009	0	1	01	01	H0978_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											88.71	50	50	50				88.71	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
H0978	009	0	1	01	01	H0978_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																								
H0978	010	0	1	01	01	H0978_010_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																								
H0978	010	0	1	01	01	H0978_010_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																								
H0978	010	0	1	01	01	H0978_010_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											106.53	25	25	25				106.53	24	24	24										25	25	25				24	24	24			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
H0978	010	0	1	01	01	H0978_010_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											86.12	45	45	45				86.12	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
H0978	010	0	1	01	01	H0978_010_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																								
H0978	011	0	1	01	01	H0978_011_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																								
H0978	011	0	1	01	01	H0978_011_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																								
H0978	011	0	1	01	01	H0978_011_0	8			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H0978	011	0	1	01	01	H0978_011_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											89.97	50	50	50				89.97	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
H0978	011	0	1	01	01	H0978_011_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																								
H0982	002	0	1	01	01	H0982_002_0	8		N	Preferred Generic	4	11	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	8		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	8		N	Preferred Brand	4	11	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	8		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										35.00		105.00										35.00		35.00
H0982	002	0	1	01	01	H0982_002_0	8		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, Supplemental Drugs																								
H0982	002	0	1	01	01	H0982_002_0	8		N	Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	007	0	1	01	01	H0982_007_0	8			Preferred Generic	4	11	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	8			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	8			Preferred Brand	4	11	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	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	000		1	30		90				2	2							30		31	70.00		210.00																																					70.00				70.00		2.33						2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00		105.00										35.00		35.00
H0982	007	0	1	01	01	H0982_007_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				303.45	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	007	0	1	01	01	H0982_007_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	008	0	1	01	01	H0982_008_0	8			Preferred Generic	4	11	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	8			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	8			Preferred Brand	4	11	1	2	3	1	110		01	000		1	30		90				2	2							30		31	20.00		55.00																																					20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										20.00		55.00										20.00		20.00
H0982	008	0	1	01	01	H0982_008_0	8			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	008	0	1	01	01	H0982_008_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				310.87	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	008	0	1	01	01	H0982_008_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	009	0	1	01	01	H0982_009_0	8			Preferred Generic	4	11	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	8			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	8			Preferred Brand	4	11	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	8			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	009	0	1	01	01	H0982_009_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				312.52	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	009	0	1	01	01	H0982_009_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	010	0	1	01	01	H0982_010_0	7		N	Preferred Generic	4	11	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	7		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	7		N	Preferred Brand	4	11	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	7		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										35.00		105.00										35.00		35.00
H0982	010	0	1	01	01	H0982_010_0	7		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, Supplemental Drugs																								
H0982	010	0	1	01	01	H0982_010_0	7		N	Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	012	0	1	01	01	H0982_012_0	7		N	Preferred Generic	4	11	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	7		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	7		N	Preferred Brand	4	11	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	7		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										35.00		105.00										35.00		35.00
H0982	012	0	1	01	01	H0982_012_0	7		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, Supplemental Drugs																								
H0982	012	0	1	01	01	H0982_012_0	7		N	Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	013	0	1	01	01	H0982_013_0	7		N	Preferred Generic	4	11	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	7		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	7		N	Preferred Brand	4	11	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	7		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										35.00		105.00										35.00		35.00
H0982	013	0	1	01	01	H0982_013_0	7		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, Supplemental Drugs																								
H0982	013	0	1	01	01	H0982_013_0	7		N	Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	016	0	1	01	01	H0982_016_0	9			Preferred Generic	4	11	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	9			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	9			Preferred Brand	4	11	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	9			Non-Preferred Drug	4	11	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										10.00		25.00										10.00		10.00
H0982	016	0	1	01	01	H0982_016_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				372.57	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	016	0	1	01	01	H0982_016_0	9			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	017	0	1	01	01	H0982_017_0	8			Preferred Generic	4	11	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	8			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	8			Preferred Brand	4	11	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	8			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	017	0	1	01	01	H0982_017_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				245.19	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	017	0	1	01	01	H0982_017_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	018	0	1	01	01	H0982_018_0	8			Preferred Generic	4	11	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	8			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	8			Preferred Brand	4	11	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	018	0	1	01	01	H0982_018_0	8			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	018	0	1	01	01	H0982_018_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				205.39	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	018	0	1	01	01	H0982_018_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	019	0	1	01	01	H0982_019_0	8			Preferred Generic	4	11	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	8			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	8			Preferred Brand	4	11	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	8			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	019	0	1	01	01	H0982_019_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				235.84	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	019	0	1	01	01	H0982_019_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	020	0	1	01	01	H0982_020_0	7			Preferred Generic	4	11	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	7			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	7			Preferred Brand	4	11	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	7			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	020	0	1	01	01	H0982_020_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				304.21	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	020	0	1	01	01	H0982_020_0	7			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	021	0	1	01	01	H0982_021_0	8			Preferred Generic	4	11	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	8			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	8			Preferred Brand	4	11	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	8			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	021	0	1	01	01	H0982_021_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				240.85	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	021	0	1	01	01	H0982_021_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	022	0	1	01	01	H0982_022_0	7			Preferred Generic	4	11	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	7			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	7			Preferred Brand	4	11	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	7			Non-Preferred Drug	4	11	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										10.00		25.00										10.00		10.00
H0982	022	0	1	01	01	H0982_022_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				318.31	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	022	0	1	01	01	H0982_022_0	7			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	023	0	1	01	01	H0982_023_0	6		N	Preferred Generic	4	11	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	023	0	1	01	01	H0982_023_0	6		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	023	0	1	01	01	H0982_023_0	6		N	Preferred Brand	4	11	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	023	0	1	01	01	H0982_023_0	6		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										35.00		105.00										35.00		35.00
H0982	023	0	1	01	01	H0982_023_0	6		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, Supplemental Drugs																								
H0982	023	0	1	01	01	H0982_023_0	6		N	Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	024	0	1	01	01	H0982_024_0	7			Preferred Generic	4	11	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	024	0	1	01	01	H0982_024_0	7			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	024	0	1	01	01	H0982_024_0	7			Preferred Brand	4	11	1	2	3	1	110		01	000		1	30		90				2	2							30		31	20.00		55.00																																					20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										20.00		55.00										20.00		20.00
H0982	024	0	1	01	01	H0982_024_0	7			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	024	0	1	01	01	H0982_024_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				323.28	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	024	0	1	01	01	H0982_024_0	7			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	025	0	1	01	01	H0982_025_0	6		N	Preferred Generic	4	11	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	025	0	1	01	01	H0982_025_0	6		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	025	0	1	01	01	H0982_025_0	6		N	Preferred Brand	4	11	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	025	0	1	01	01	H0982_025_0	6		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										35.00		105.00										35.00		35.00
H0982	025	0	1	01	01	H0982_025_0	6		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, Supplemental Drugs																								
H0982	025	0	1	01	01	H0982_025_0	6		N	Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	026	0	1	01	01	H0982_026_0	8			Preferred Generic	4	11	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	026	0	1	01	01	H0982_026_0	8			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	026	0	1	01	01	H0982_026_0	8			Preferred Brand	4	11	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	026	0	1	01	01	H0982_026_0	8			Non-Preferred Drug	4	11	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										35.00		105.00										35.00		35.00
H0982	026	0	1	01	01	H0982_026_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				241.54	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	026	0	1	01	01	H0982_026_0	8			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H0982	027	0	1	01	01	H0982_027_0	7			Preferred Generic	4	11	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	027	0	1	01	01	H0982_027_0	7			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	027	0	1	01	01	H0982_027_0	7			Preferred Brand	4	11	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	027	0	1	01	01	H0982_027_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	000		1	30		90				2	2							30		31				1.10	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	027	0	1	01	01	H0982_027_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				455.12	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H0982	027	0	1	01	01	H0982_027_0	7			Supplemental Drugs	4	01	2	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, Supplemental Drugs																								
H1016	001	0	1	01	01	H1016_001_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	001	0	1	01	01	H1016_001_0	4			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	37.50					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, Select Care Drugs																								
H1016	001	0	1	01	01	H1016_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	117.50					25.00	50.00	62.50					25.00	50.00	62.50																47.00				25.00			1.57	0.83	0.83			0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	25.00	50.00	62.50	25.00	50.00	62.50				35.00		25.00
H1016	001	0	1	01	01	H1016_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	250.00					35.00	70.00	87.50					35.00	70.00	87.50																100.00				35.00			3.33	1.17	1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	001	0	1	01	01	H1016_001_0	4			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, Select Care Drugs																								
H1016	001	0	1	01	01	H1016_001_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 Drug, Specialty Tier, Select Care Drugs																								
H1016	021	0	1	01	01	H1016_021_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	021	0	1	01	01	H1016_021_0	4			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	37.50					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, Select Care Drugs																								
H1016	021	0	1	01	01	H1016_021_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					30.00	60.00	75.00					30.00	60.00	75.00																30.00				30.00			1.57	1.00	1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				30.00		30.00
H1016	021	0	1	01	01	H1016_021_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					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, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	021	0	1	01	01	H1016_021_0	4			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, Select Care Drugs																								
H1016	021	0	1	01	01	H1016_021_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 Drug, Specialty Tier, Select Care Drugs																								
H1016	023	0	1	01	01	H1016_023_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	023	0	1	01	01	H1016_023_0	4			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	37.50					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, Select Care Drugs																								
H1016	023	0	1	01	01	H1016_023_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					0.00	0.00	0.00					0.00	0.00	0.00																47.00				0.00			1.57	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	0.00	0.00	0.00	0.00	0.00	0.00				35.00		0.00
H1016	023	0	1	01	01	H1016_023_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					35.00	70.00	87.50					35.00	70.00	87.50																100.00				35.00			3.33	1.17	1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	023	0	1	01	01	H1016_023_0	4			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, Select Care Drugs																								
H1016	023	0	1	01	01	H1016_023_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 Drug, Specialty Tier, Select Care Drugs																								
H1016	024	0	1	01	01	H1016_024_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	024	0	1	01	01	H1016_024_0	4			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	37.50					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, Select Care Drugs																								
H1016	024	0	1	01	01	H1016_024_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					10.00	20.00	25.00					10.00	20.00	25.00																47.00				10.00			1.57	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	10.00	20.00	25.00	10.00	20.00	25.00				35.00		10.00
H1016	024	0	1	01	01	H1016_024_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					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, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	024	0	1	01	01	H1016_024_0	4			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, Select Care Drugs																								
H1016	024	0	1	01	01	H1016_024_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 Drug, Specialty Tier, Select Care Drugs																								
H1016	025	0	1	02	01	H1016_025_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	025	0	1	02	01	H1016_025_0	4			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	37.50					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, Select Care Drugs																								
H1016	025	0	1	02	01	H1016_025_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					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, Select Care Drugs										35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		30.00
H1016	025	0	1	02	01	H1016_025_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					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, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	025	0	1	02	01	H1016_025_0	4			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, Select Care Drugs																								
H1016	025	0	1	02	01	H1016_025_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 Drug, Specialty Tier, Select Care Drugs																								
H1016	026	0	1	02	01	H1016_026_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	026	0	1	02	01	H1016_026_0	4			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	37.50					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, Select Care Drugs																								
H1016	026	0	1	02	01	H1016_026_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					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, Select Care Drugs										35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		30.00
H1016	026	0	1	02	01	H1016_026_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					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, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	026	0	1	02	01	H1016_026_0	4			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, Select Care Drugs																								
H1016	026	0	1	02	01	H1016_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1016	031	0	1	01	01	H1016_031_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	031	0	1	01	01	H1016_031_0	4			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	37.50					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, Select Care Drugs																								
H1016	031	0	1	01	01	H1016_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	117.50					0.00	0.00	0.00					0.00	0.00	0.00																47.00				0.00			1.57	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	0.00	0.00	0.00	0.00	0.00	0.00				35.00		0.00
H1016	031	0	1	01	01	H1016_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								100.00	200.00	250.00					35.00	70.00	87.50					35.00	70.00	87.50																100.00				35.00			3.33	1.17	1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	031	0	1	01	01	H1016_031_0	4			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, Select Care Drugs																								
H1016	031	0	1	01	01	H1016_031_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 Drug, Specialty Tier, Select Care Drugs																								
H1016	032	0	1	01	01	H1016_032_0	4			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	032	0	1	01	01	H1016_032_0	4			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	37.50					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, Select Care Drugs																								
H1016	032	0	1	01	01	H1016_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	117.50					10.00	20.00	25.00					10.00	20.00	25.00																47.00				10.00			1.57	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	87.50	10.00	20.00	25.00	10.00	20.00	25.00				35.00		10.00
H1016	032	0	1	01	01	H1016_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								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, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	032	0	1	01	01	H1016_032_0	4			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, Select Care Drugs																								
H1016	032	0	1	01	01	H1016_032_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 Drug, Specialty Tier, Select Care Drugs																								
H1016	033	0	1	01	01	H1016_033_0	5			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	033	0	1	01	01	H1016_033_0	5			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	37.50					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, Select Care Drugs																								
H1016	033	0	1	01	01	H1016_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	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, Select Care Drugs										35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		30.00
H1016	033	0	1	01	01	H1016_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	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, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	033	0	1	01	01	H1016_033_0	5			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, Select Care Drugs																								
H1016	033	0	1	01	01	H1016_033_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1016	034	0	1	01	01	H1016_034_0	5			Preferred Generic	4	01	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, Select Care Drugs																								
H1016	034	0	1	01	01	H1016_034_0	5			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	37.50					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, Select Care Drugs																								
H1016	034	0	1	01	01	H1016_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	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, Select Care Drugs										35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		30.00
H1016	034	0	1	01	01	H1016_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	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, Select Care Drugs										35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50				35.00		35.00
H1016	034	0	1	01	01	H1016_034_0	5			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, Select Care Drugs																								
H1016	034	0	1	01	01	H1016_034_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1019	001	0	1	02	01	H1019_001_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																									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	02	01	H1019_001_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																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, 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	02	01	H1019_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	02	01	H1019_001_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	39		39																								39		39				39		39			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
H1019	001	0	1	02	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	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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	5			Generic	4	11	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				0.00	0.00	0.00	Preferred Generic, 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	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	006	0	1	01	01	H1019_006_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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		35.00
H1019	006	0	1	01	01	H1019_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
H1019	023	0	1	01	01	H1019_023_0	5		N	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
H1019	023	0	1	01	01	H1019_023_0	5		N	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
H1019	023	0	1	01	01	H1019_023_0	5		N	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		70.00	35.00		35.00
H1019	023	0	1	01	01	H1019_023_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	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
H1019	023	0	1	01	01	H1019_023_0	5		N	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
H1019	043	0	1	02	01	H1019_043_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
H1019	043	0	1	02	01	H1019_043_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
H1019	043	0	1	02	01	H1019_043_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	02	01	H1019_043_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	35		35																								48		48				35		35			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
H1019	043	0	1	02	01	H1019_043_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	057	0	1	02	01	H1019_057_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
H1019	057	0	1	02	01	H1019_057_0	4			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
H1019	057	0	1	02	01	H1019_057_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	35		35																								50		50				35		35			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
H1019	057	0	1	02	01	H1019_057_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
H1019	065	0	1	01	01	H1019_065_0	3			Preferred Generic	4	11	3	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
H1019	065	0	1	01	01	H1019_065_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	065	0	1	01	01	H1019_065_0	3			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																									97.00		291.00				97.00		194.00				97.00				97.00		3.23				3.23	3.23	3.13	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
H1019	065	0	1	01	01	H1019_065_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										35.00						35.00			35.00			35.00		35.00
H1019	073	0	1	01	01	H1019_073_0	4		N	Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				1.00	24		24																								24		24				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H1019	073	0	1	01	01	H1019_073_0	4		N	Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H1019	073	0	1	01	01	H1019_073_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	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
H1019	073	0	1	01	01	H1019_073_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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
H1019	073	0	1	01	01	H1019_073_0	4		N	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
H1019	076	0	1	01	01	H1019_076_0	3			Preferred Generic	4	11	3	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
H1019	076	0	1	01	01	H1019_076_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	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
H1019	076	0	1	01	01	H1019_076_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	076	0	1	01	01	H1019_076_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	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		105.00	35.00		35.00
H1019	076	0	1	01	01	H1019_076_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										35.00						35.00			35.00			35.00		35.00
H1019	094	0	1	01	01	H1019_094_0	3			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
H1019	094	0	1	01	01	H1019_094_0	3			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
H1019	094	0	1	01	01	H1019_094_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	094	0	1	01	01	H1019_094_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	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		105.00	35.00		35.00
H1019	094	0	1	01	01	H1019_094_0	3			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		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
H1019	098	0	1	01	01	H1019_098_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
H1019	098	0	1	01	01	H1019_098_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	098	0	1	01	01	H1019_098_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	35		35																								48		48				35		35			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
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	103	1	1	01	01	H1019_103_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
H1019	103	1	1	01	01	H1019_103_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
H1019	103	1	1	01	01	H1019_103_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				58.00	32		32																								50		50				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
H1019	103	1	1	01	01	H1019_103_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	103	2	1	01	01	H1019_103_2	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
H1019	103	2	1	01	01	H1019_103_2	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
H1019	103	2	1	01	01	H1019_103_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				58.00	32		32																								50		50				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
H1019	103	2	1	01	01	H1019_103_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	104	1	1	01	01	H1019_104_1	3			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
H1019	104	1	1	01	01	H1019_104_1	3			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
H1019	104	1	1	01	01	H1019_104_1	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	104	1	1	01	01	H1019_104_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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		105.00	35.00		35.00
H1019	104	1	1	01	01	H1019_104_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 Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1019	104	2	1	01	01	H1019_104_2	3			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
H1019	104	2	1	01	01	H1019_104_2	3			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
H1019	104	2	1	01	01	H1019_104_2	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	104	2	1	01	01	H1019_104_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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		105.00	35.00		35.00
H1019	104	2	1	01	01	H1019_104_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 Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1019	108	0	1	01	01	H1019_108_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, Select Care Drugs										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	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, Select Care Drugs										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	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		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		95.00	35.00		35.00
H1019	108	0	1	01	01	H1019_108_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	50		50																								50		50				50		50			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		35.00
H1019	108	0	1	01	01	H1019_108_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
H1019	108	0	1	01	01	H1019_108_0	8			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				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
H1019	109	0	1	01	01	H1019_109_0	3			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, Select Care Drugs										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	3			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
H1019	109	0	1	01	01	H1019_109_0	3			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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	109	0	1	01	01	H1019_109_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				89.00	50		50																								50		50				50		50			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		35.00
H1019	109	0	1	01	01	H1019_109_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	109	0	1	01	01	H1019_109_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				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
H1019	113	0	1	01	01	H1019_113_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
H1019	113	0	1	01	01	H1019_113_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
H1019	113	0	1	01	01	H1019_113_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		95.00	35.00		35.00
H1019	113	0	1	01	01	H1019_113_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				89.00	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
H1019	113	0	1	01	01	H1019_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
H1019	117	0	1	01	01	H1019_117_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, Select Care Drugs										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	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
H1019	117	0	1	01	01	H1019_117_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	117	0	1	01	01	H1019_117_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	85.00		255.00																									85.00		255.00				85.00		245.00				85.00				85.00		2.83				2.83	2.83	2.74	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
H1019	117	0	1	01	01	H1019_117_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
H1019	117	0	1	01	01	H1019_117_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				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
H1019	118	0	1	01	01	H1019_118_0	3			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, Select Care Drugs										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	3			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
H1019	118	0	1	01	01	H1019_118_0	3			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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	118	0	1	01	01	H1019_118_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	50		50																								50		50				50		50			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		35.00
H1019	118	0	1	01	01	H1019_118_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	118	0	1	01	01	H1019_118_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				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
H1019	121	0	1	01	01	H1019_121_0	3			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	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				1.00		3.00	0.00		0.00	0.00		0.00
H1019	121	0	1	01	01	H1019_121_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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, Select Care Drugs										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	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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										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	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	50		50																								50		50				50		50			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		35.00
H1019	121	0	1	01	01	H1019_121_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	121	0	1	01	01	H1019_121_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				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
H1019	123	0	1	01	01	H1019_123_0	3			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	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				1.00		3.00	0.00		0.00	0.00		0.00
H1019	123	0	1	01	01	H1019_123_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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, Select Care Drugs										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	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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										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	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	50		50																								50		50				50		50			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		35.00
H1019	123	0	1	01	01	H1019_123_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	123	0	1	01	01	H1019_123_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				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
H1019	124	0	1	01	01	H1019_124_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																									0.00		0.00				0.00		0.00				0.00				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
H1019	124	0	1	01	01	H1019_124_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																									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, Select Care Drugs										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	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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	124	0	1	01	01	H1019_124_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	50		50																								50		50				50		50			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		35.00
H1019	124	0	1	01	01	H1019_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	124	0	1	01	01	H1019_124_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				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
H1019	130	0	1	01	01	H1019_130_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																									0.00		0.00				0.00		0.00				0.00				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
H1019	130	0	1	01	01	H1019_130_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																									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, Select Care Drugs										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	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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	130	0	1	01	01	H1019_130_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	50		50																								50		50				50		50			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		35.00
H1019	130	0	1	01	01	H1019_130_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
H1019	130	0	1	01	01	H1019_130_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				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
H1019	134	0	1	01	01	H1019_134_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
H1019	134	0	1	01	01	H1019_134_0	4			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
H1019	134	0	1	01	01	H1019_134_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	134	0	1	01	01	H1019_134_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				60.00	32		32																								50		50				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
H1019	134	0	1	01	01	H1019_134_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
H1019	135	0	1	02	01	H1019_135_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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	02	01	H1019_135_0	4			Generic	4	11	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				0.00	0.00	0.00	Preferred Generic, 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	02	01	H1019_135_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									30.00		90.00				30.00		60.00				30.00				30.00		1.00				1.00	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00		90.00				30.00		90.00	30.00		60.00	30.00		30.00
H1019	135	0	1	02	01	H1019_135_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	85.00		255.00																									85.00		255.00				85.00		170.00				85.00				85.00		2.83				2.83	2.83	2.74	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
H1019	135	0	1	02	01	H1019_135_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
H1019	136	0	1	01	01	H1019_136_0	3			Preferred Generic	4	11	3	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
H1019	136	0	1	01	01	H1019_136_0	3			Generic	4	11	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				0.00	0.00	0.00	Preferred Generic, 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	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	136	0	1	01	01	H1019_136_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				21.00	10		10																								12		12				10		10			10			10								Preferred Generic, 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	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										35.00						35.00			35.00			35.00		35.00
H1019	138	0	1	01	01	H1019_138_0	3			Preferred Generic	4	11	3	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
H1019	138	0	1	01	01	H1019_138_0	3			Generic	4	11	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				0.00	0.00	0.00	Preferred Generic, 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	138	0	1	01	01	H1019_138_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									30.00		90.00				15.00		30.00				15.00				15.00		0.50				1.00	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00		45.00				30.00		90.00	15.00		30.00	15.00		15.00
H1019	138	0	1	01	01	H1019_138_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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
H1019	138	0	1	01	01	H1019_138_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										35.00						35.00			35.00			35.00		35.00
H1019	139	0	1	01	01	H1019_139_0	3			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
H1019	139	0	1	01	01	H1019_139_0	3			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
H1019	139	0	1	01	01	H1019_139_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	139	0	1	01	01	H1019_139_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	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		105.00	35.00		35.00
H1019	139	0	1	01	01	H1019_139_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										35.00						35.00			35.00			35.00		35.00
H1019	140	0	1	01	01	H1019_140_0	3			Preferred Generic	4	11	3	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
H1019	140	0	1	01	01	H1019_140_0	3			Generic	4	11	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				0.00	0.00	0.00	Preferred Generic, 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	140	0	1	01	01	H1019_140_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									30.00		90.00				30.00		60.00				30.00				30.00		1.00				1.00	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00		90.00				30.00		90.00	30.00		60.00	30.00		30.00
H1019	140	0	1	01	01	H1019_140_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				64.00	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		105.00	35.00		35.00
H1019	140	0	1	01	01	H1019_140_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										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		100				1	2				30		100	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			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									16.00		48.00				0.00		0.00				0.00				0.00		0.00				0.53	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00				16.00		48.00	0.00		0.00	0.00		0.00
H1019	144	0	1	01	01	H1019_144_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	144	0	1	01	01	H1019_144_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	35		35																								50		50				35		35			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
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
H1019	146	0	1	01	01	H1019_146_0	5		N	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
H1019	146	0	1	01	01	H1019_146_0	5		N	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
H1019	146	0	1	01	01	H1019_146_0	5		N	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		70.00	35.00		35.00
H1019	146	0	1	01	01	H1019_146_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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
H1019	146	0	1	01	01	H1019_146_0	5		N	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
H1019	147	1	1	01	01	H1019_147_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																									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, Select Care Drugs										0.00		0.00				2.00		6.00	0.00		0.00	0.00		0.00
H1019	147	1	1	01	01	H1019_147_1	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									16.00		48.00				0.00		0.00				0.00				0.00		0.00				0.53	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00				16.00		48.00	0.00		0.00	0.00		0.00
H1019	147	1	1	01	01	H1019_147_1	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1019	147	1	1	01	01	H1019_147_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	35		35																								50		50				35		35			35			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
H1019	147	1	1	01	01	H1019_147_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	147	1	1	01	01	H1019_147_1	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				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
H1019	147	2	1	01	01	H1019_147_2	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																									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, Select Care Drugs										0.00		0.00				2.00		6.00	0.00		0.00	0.00		0.00
H1019	147	2	1	01	01	H1019_147_2	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									16.00		48.00				0.00		0.00				0.00				0.00		0.00				0.53	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00				16.00		48.00	0.00		0.00	0.00		0.00
H1019	147	2	1	01	01	H1019_147_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1019	147	2	1	01	01	H1019_147_2	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	35		35																								50		50				35		35			35			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
H1019	147	2	1	01	01	H1019_147_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	147	2	1	01	01	H1019_147_2	6			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				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
H1019	148	0	1	01	01	H1019_148_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																									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	148	0	1	01	01	H1019_148_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																									16.00		48.00				0.00		0.00				0.00				0.00		0.00				0.53	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00				16.00		48.00	0.00		0.00	0.00		0.00
H1019	148	0	1	01	01	H1019_148_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	148	0	1	01	01	H1019_148_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	35		35																								48		48				35		35			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
H1019	148	0	1	01	01	H1019_148_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	149	0	1	01	01	H1019_149_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
H1019	149	0	1	01	01	H1019_149_0	4			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
H1019	149	0	1	01	01	H1019_149_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1019	149	0	1	01	01	H1019_149_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	70.00		210.00																									85.00		255.00				70.00		140.00				70.00				70.00		2.33				2.83	2.33	2.26	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
H1019	149	0	1	01	01	H1019_149_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
H1019	150	0	1	01	01	H1019_150_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																									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, Select Care Drugs										0.00		0.00				2.00		6.00	0.00		0.00	0.00		0.00
H1019	150	0	1	01	01	H1019_150_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																									16.00		48.00				0.00		0.00				0.00				0.00		0.00				0.53	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00				16.00		48.00	0.00		0.00	0.00		0.00
H1019	150	0	1	01	01	H1019_150_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		80.00				40.00				40.00		1.33				1.57	1.33	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		70.00	35.00		35.00
H1019	150	0	1	01	01	H1019_150_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	50		50																								50		50				50		50			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		35.00
H1019	150	0	1	01	01	H1019_150_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
H1019	150	0	1	01	01	H1019_150_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				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
H1019	151	1	1	01	01	H1019_151_1	3			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	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, Select Care Drugs										0.00		0.00				2.00		6.00	0.00		0.00	0.00		0.00
H1019	151	1	1	01	01	H1019_151_1	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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, Select Care Drugs										5.00		15.00				16.00		48.00	5.00		0.00	5.00		5.00
H1019	151	1	1	01	01	H1019_151_1	3			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		95.00	35.00		35.00
H1019	151	1	1	01	01	H1019_151_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	50		50																								50		50				50		50			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		35.00
H1019	151	1	1	01	01	H1019_151_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 Drug, Specialty Tier, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	151	1	1	01	01	H1019_151_1	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				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
H1019	151	2	1	01	01	H1019_151_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																									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, Select Care Drugs										0.00		0.00				2.00		6.00	0.00		0.00	0.00		0.00
H1019	151	2	1	01	01	H1019_151_2	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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, Select Care Drugs										5.00		15.00				16.00		48.00	5.00		0.00	5.00		5.00
H1019	151	2	1	01	01	H1019_151_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	151	2	1	01	01	H1019_151_2	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	50		50																								50		50				50		50			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		35.00
H1019	151	2	1	01	01	H1019_151_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1019	151	2	1	01	01	H1019_151_2	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				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
H1032	190	0	1	01	01	H1032_190_0	5			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																								
H1032	190	0	1	01	01	H1032_190_0	5			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																								
H1032	190	0	1	01	01	H1032_190_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.49	25	25	25				153.49	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
H1032	190	0	1	01	01	H1032_190_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											75.13	46	46	46				75.13	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	190	0	1	01	01	H1032_190_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, Select Care Drugs																								
H1032	190	0	1	01	01	H1032_190_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																								
H1032	191	0	1	01	01	H1032_191_0	4			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																								
H1032	191	0	1	01	01	H1032_191_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	20.00	30.00				0.00	0.00	0.00				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																								
H1032	191	0	1	01	01	H1032_191_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.64	25	25	25				161.64	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
H1032	191	0	1	01	01	H1032_191_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											50.53	43	43	43				49.35	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
H1032	191	0	1	01	01	H1032_191_0	4			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																								
H1032	191	0	1	01	01	H1032_191_0	4			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	5			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																								
H1032	192	0	1	01	01	H1032_192_0	5			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																								
H1032	192	0	1	01	01	H1032_192_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											152.97	25	25	25				152.97	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
H1032	192	0	1	01	01	H1032_192_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											53.11	48	48	48				53.11	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
H1032	192	0	1	01	01	H1032_192_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, Select Care Drugs																								
H1032	192	0	1	01	01	H1032_192_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																								
H1032	193	0	1	01	01	H1032_193_0	5			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																								
H1032	193	0	1	01	01	H1032_193_0	5			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																								
H1032	193	0	1	01	01	H1032_193_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.54	25	25	25				161.54	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
H1032	193	0	1	01	01	H1032_193_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											64.48	37	37	37				64.48	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
H1032	193	0	1	01	01	H1032_193_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, Select Care Drugs																								
H1032	193	0	1	01	01	H1032_193_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																								
H1032	194	0	1	01	01	H1032_194_0	5			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																								
H1032	194	0	1	01	01	H1032_194_0	5			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																								
H1032	194	0	1	01	01	H1032_194_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											149.21	25	25	25				149.21	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
H1032	194	0	1	01	01	H1032_194_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											57.52	40	40	40				56.08	39	39	39										40	40	40				39	39	39			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
H1032	194	0	1	01	01	H1032_194_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, Select Care Drugs																								
H1032	194	0	1	01	01	H1032_194_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																								
H1032	195	0	1	01	01	H1032_195_0	5			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																								
H1032	195	0	1	01	01	H1032_195_0	5			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																								
H1032	195	0	1	01	01	H1032_195_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											150.56	25	25	25				150.56	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
H1032	195	0	1	01	01	H1032_195_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											68.20	32	32	32				68.20	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
H1032	195	0	1	01	01	H1032_195_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, Select Care Drugs																								
H1032	195	0	1	01	01	H1032_195_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																								
H1032	196	0	1	01	01	H1032_196_0	5			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																								
H1032	196	0	1	01	01	H1032_196_0	5			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																								
H1032	196	0	1	01	01	H1032_196_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.18	25	25	25				154.18	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
H1032	196	0	1	01	01	H1032_196_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											73.08	36	36	36				71.05	35	35	35										36	36	36				35	35	35			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	196	0	1	01	01	H1032_196_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, Select Care Drugs																								
H1032	196	0	1	01	01	H1032_196_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																								
H1032	198	0	1	01	01	H1032_198_0	5			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																								
H1032	198	0	1	01	01	H1032_198_0	5			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																								
H1032	198	0	1	01	01	H1032_198_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											160.88	25	25	25				160.88	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
H1032	198	0	1	01	01	H1032_198_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											63.69	42	42	42				63.69	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	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, Select Care Drugs																								
H1032	198	0	1	01	01	H1032_198_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																								
H1032	199	0	1	01	01	H1032_199_0	5			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																								
H1032	199	0	1	01	01	H1032_199_0	5			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																								
H1032	199	0	1	01	01	H1032_199_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											152.75	25	25	25				152.75	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
H1032	199	0	1	01	01	H1032_199_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											73.48	40	40	40				73.48	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
H1032	199	0	1	01	01	H1032_199_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, Select Care Drugs																								
H1032	199	0	1	01	01	H1032_199_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																								
H1032	200	0	1	01	01	H1032_200_0	5			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																								
H1032	200	0	1	01	01	H1032_200_0	5			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																								
H1032	200	0	1	01	01	H1032_200_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.33	25	25	25				155.33	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
H1032	200	0	1	01	01	H1032_200_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											55.26	39	39	39				55.26	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
H1032	200	0	1	01	01	H1032_200_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, Select Care Drugs																								
H1032	200	0	1	01	01	H1032_200_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																								
H1032	201	0	1	01	01	H1032_201_0	5			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																								
H1032	201	0	1	01	01	H1032_201_0	5			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																								
H1032	201	0	1	01	01	H1032_201_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											144.10	25	25	25				144.10	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											43.42	35	35	35				42.18	34	34	34										35	35	35				34	34	34			35			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
H1032	201	0	1	01	01	H1032_201_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, Select Care Drugs																								
H1032	201	0	1	01	01	H1032_201_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																								
H1032	204	0	1	01	01	H1032_204_0	5			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																								
H1032	204	0	1	01	01	H1032_204_0	5			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																								
H1032	204	0	1	01	01	H1032_204_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.01	25	25	25				153.01	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
H1032	204	0	1	01	01	H1032_204_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											48.67	40	40	40				47.45	39	39	39										40	40	40				39	39	39			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
H1032	204	0	1	01	01	H1032_204_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, Select Care Drugs																								
H1032	204	0	1	01	01	H1032_204_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																								
H1032	205	0	1	01	01	H1032_205_0	5			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																								
H1032	205	0	1	01	01	H1032_205_0	5			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																								
H1032	205	0	1	01	01	H1032_205_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.41	25	25	25				151.41	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
H1032	205	0	1	01	01	H1032_205_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											39.36	45	45	45				39.36	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	205	0	1	01	01	H1032_205_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, Select Care Drugs																								
H1032	205	0	1	01	01	H1032_205_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																								
H1032	210	0	1	01	01	H1032_210_0	5			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																								
H1032	210	0	1	01	01	H1032_210_0	5			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																								
H1032	210	0	1	01	01	H1032_210_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.06	25	25	25				158.06	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
H1032	210	0	1	01	01	H1032_210_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											56.77	38	38	38				55.28	37	37	37										38	38	38				37	37	37			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
H1032	210	0	1	01	01	H1032_210_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, Select Care Drugs																								
H1032	210	0	1	01	01	H1032_210_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																								
H1032	211	0	1	01	01	H1032_211_0	5			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																								
H1032	211	0	1	01	01	H1032_211_0	5			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																								
H1032	211	0	1	01	01	H1032_211_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											146.79	25	25	25				146.79	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
H1032	211	0	1	01	01	H1032_211_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											72.15	50	50	50				70.71	49	49	49										50	50	50				49	49	49			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	211	0	1	01	01	H1032_211_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, Select Care Drugs																								
H1032	211	0	1	01	01	H1032_211_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																								
H1032	212	0	1	01	01	H1032_212_0	5			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																								
H1032	212	0	1	01	01	H1032_212_0	5			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																								
H1032	212	0	1	01	01	H1032_212_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											150.43	25	25	25				150.43	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
H1032	212	0	1	01	01	H1032_212_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											58.43	35	35	35				56.76	34	34	34										35	35	35				34	34	34			35			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
H1032	212	0	1	01	01	H1032_212_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, Select Care Drugs																								
H1032	212	0	1	01	01	H1032_212_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																								
H1032	213	0	1	01	01	H1032_213_0	5			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																								
H1032	213	0	1	01	01	H1032_213_0	5			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																								
H1032	213	0	1	01	01	H1032_213_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											146.46	25	25	25				146.46	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											58.83	38	38	38				57.28	37	37	37										38	38	38				37	37	37			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
H1032	213	0	1	01	01	H1032_213_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, Select Care Drugs																								
H1032	213	0	1	01	01	H1032_213_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																								
H1032	218	0	1	01	01	H1032_218_0	5			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																								
H1032	218	0	1	01	01	H1032_218_0	5			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																								
H1032	218	0	1	01	01	H1032_218_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.14	25	25	25				156.14	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
H1032	218	0	1	01	01	H1032_218_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											70.62	42	42	42				70.62	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	218	0	1	01	01	H1032_218_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, Select Care Drugs																								
H1032	218	0	1	01	01	H1032_218_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																								
H1032	237	0	1	01	01	H1032_237_0	5			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																								
H1032	237	0	1	01	01	H1032_237_0	5			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																								
H1032	237	0	1	01	01	H1032_237_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											145.91	25	25	25				105.06	18	18	18										25	25	25				18	18	18			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
H1032	237	0	1	01	01	H1032_237_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											50.60	40	40	40				40.48	32	32	32										40	40	40				32	32	32			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
H1032	237	0	1	01	01	H1032_237_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																								
H1032	237	0	1	01	01	H1032_237_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																								
H1035	002	0	1	02	01	H1035_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	1	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										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	6			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	1	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										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	6			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	1	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										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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	101		1				31	62	93	1	1		62	93				31		31											102.58	25	25	25				134.86	25	25	25					25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	6			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1196.54	33						690.31	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00			35.00									35.00		35.00
H1035	002	0	1	02	01	H1035_002_0	6			Vaccines	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																								
H1035	014	0	1	01	01	H1035_014_0	5			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	1	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										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	5			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	1	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										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	5			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	1	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										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	101		1				31	62	93	1	1		62	93				31		31											369.31	25	25	25				119.28	25	25	25					25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1092.54	25						584.59	25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00			35.00									35.00		35.00
H1035	014	0	1	01	01	H1035_014_0	5			Vaccines	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																								
H1035	017	0	1	01	01	H1035_017_0	8			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	8			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	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	15.00		45.00																			15.00		45.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00		45.00				15.00		45.00				15.00		15.00
H1035	017	0	1	01	01	H1035_017_0	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				191.45	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
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			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				120.06	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	020	0	1	01	01	H1035_020_0	8			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	8			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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				193.79	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	8			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	8			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	8			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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				145.59	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	8			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	022	0	1	01	01	H1035_022_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	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			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				131.78	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	8			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	025	0	1	01	01	H1035_025_0	8			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	8			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	025	0	1	01	01	H1035_025_0	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				128.71	33																				33																	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	8			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	026	0	1	01	01	H1035_026_0	8			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	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	15.00		45.00																			15.00		45.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00		45.00				15.00		45.00				15.00		15.00
H1035	026	0	1	01	01	H1035_026_0	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				131.43	33																				33																	33			33								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	8			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	033	0	1	01	01	H1035_033_0	8			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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				114.17	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	8			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	034	0	1	01	01	H1035_034_0	8			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	8			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	034	0	1	01	01	H1035_034_0	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				144.17	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	6			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	1	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										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	6			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	1	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										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	6			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	1	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										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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	101		1				31	62	93	1	1		62	93				31		31											297.40	25	25	25				126.71	25	25	25					25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	6			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											948.26	29						614.37	29																							29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00			35.00									35.00		35.00
H1035	040	0	1	01	01	H1035_040_0	6			Vaccines	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																								
H1035	043	0	1	01	01	H1035_043_0	8			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	043	0	1	01	01	H1035_043_0	8			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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				115.50	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	8			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	045	0	1	01	01	H1035_045_0	8			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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				120.28	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H1035	048	0	1	01	01	H1035_048_0	8			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	048	0	1	01	01	H1035_048_0	8			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	8			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	048	0	1	01	01	H1035_048_0	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				232.27	33																				33																	33			33								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	8			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	052	0	1	01	01	H1035_052_0	8			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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				125.43	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		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	025	0	1	01	01	H1036_025_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
H1036	025	0	1	01	01	H1036_025_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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		100				2	2				30		100	30		31	55.00		165.00																									70.00		210.00				55.00		110.00				55.00				55.00		1.83				2.33	1.83	1.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		70.00	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	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
H1036	044	0	1	01	01	H1036_044_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
H1036	044	0	1	01	01	H1036_044_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	044	0	1	01	01	H1036_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	60.00		180.00																									75.00		225.00				60.00		120.00				60.00				60.00		2.00				2.50	2.00	1.94	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
H1036	044	0	1	01	01	H1036_044_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	054	0	1	01	01	H1036_054_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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	25.00		75.00																									25.00		75.00				25.00		65.00				25.00				25.00		0.83				0.83	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00		75.00				25.00		75.00	25.00		65.00	25.00		25.00
H1036	054	0	1	01	01	H1036_054_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	062	0	1	01	01	H1036_062_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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	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	062	0	1	01	01	H1036_062_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	35		35																								41		41				35		35			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
H1036	062	0	1	01	01	H1036_062_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	065	0	1	01	01	H1036_065_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																									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			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	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	065	0	1	01	01	H1036_065_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	35		35																								45		45				35		35			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
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	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
H1036	068	0	1	01	01	H1036_068_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
H1036	068	0	1	01	01	H1036_068_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	068	0	1	01	01	H1036_068_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	35		35																								50		50				35		35			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
H1036	068	0	1	01	01	H1036_068_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	074	0	1	01	01	H1036_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
H1036	074	0	1	01	01	H1036_074_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
H1036	074	0	1	01	01	H1036_074_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									60.00		180.00				45.00		90.00				45.00				45.00		1.50				2.00	1.50	1.45	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
H1036	074	0	1	01	01	H1036_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
H1036	077	0	1	01	01	H1036_077_0	7		N	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	077	0	1	01	01	H1036_077_0	7		N	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	077	0	1	01	01	H1036_077_0	7		N	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		70.00	35.00		35.00
H1036	077	0	1	01	01	H1036_077_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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
H1036	077	0	1	01	01	H1036_077_0	7		N	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
H1036	102	0	1	01	01	H1036_102_0	7		N	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	102	0	1	01	01	H1036_102_0	7		N	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	102	0	1	01	01	H1036_102_0	7		N	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		70.00	35.00		35.00
H1036	102	0	1	01	01	H1036_102_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	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
H1036	102	0	1	01	01	H1036_102_0	7		N	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
H1036	121	0	1	01	01	H1036_121_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																									0.00		0.00				0.00		0.00				0.00				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	121	0	1	01	01	H1036_121_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																									10.00		30.00				0.00		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	121	0	1	01	01	H1036_121_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1036	121	0	1	01	01	H1036_121_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	35		35																								50		50				35		35			35			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	121	0	1	01	01	H1036_121_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	121	0	1	01	01	H1036_121_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				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	137	0	1	02	01	H1036_137_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
H1036	137	0	1	02	01	H1036_137_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
H1036	137	0	1	02	01	H1036_137_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		95.00	35.00		35.00
H1036	137	0	1	02	01	H1036_137_0	4			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																								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
H1036	137	0	1	02	01	H1036_137_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
H1036	143	0	1	01	01	H1036_143_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
H1036	143	0	1	01	01	H1036_143_0	4			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
H1036	143	0	1	01	01	H1036_143_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		95.00	35.00		35.00
H1036	143	0	1	01	01	H1036_143_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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
H1036	143	0	1	01	01	H1036_143_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
H1036	146	0	1	01	01	H1036_146_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	146	0	1	01	01	H1036_146_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	146	0	1	01	01	H1036_146_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	146	0	1	01	01	H1036_146_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	32		32																								48		48				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
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	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
H1036	151	0	1	01	01	H1036_151_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
H1036	151	0	1	01	01	H1036_151_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		95.00	35.00		35.00
H1036	151	0	1	01	01	H1036_151_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H1036	151	0	1	01	01	H1036_151_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
H1036	153	0	1	01	01	H1036_153_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
H1036	153	0	1	01	01	H1036_153_0	4			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
H1036	153	0	1	01	01	H1036_153_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		95.00	35.00		35.00
H1036	153	0	1	01	01	H1036_153_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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
H1036	153	0	1	01	01	H1036_153_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
H1036	157	0	1	01	01	H1036_157_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	157	0	1	01	01	H1036_157_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	157	0	1	01	01	H1036_157_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	157	0	1	01	01	H1036_157_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	70.00		210.00																									85.00		255.00				70.00		140.00				70.00				70.00		2.33				2.83	2.33	2.26	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
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	209	0	1	01	01	H1036_209_0	7		N	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	209	0	1	01	01	H1036_209_0	7		N	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	209	0	1	01	01	H1036_209_0	7		N	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		70.00	35.00		35.00
H1036	209	0	1	01	01	H1036_209_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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
H1036	209	0	1	01	01	H1036_209_0	7		N	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
H1036	210	0	1	01	01	H1036_210_0	8		N	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	210	0	1	01	01	H1036_210_0	8		N	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	210	0	1	01	01	H1036_210_0	8		N	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		70.00	35.00		35.00
H1036	210	0	1	01	01	H1036_210_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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
H1036	210	0	1	01	01	H1036_210_0	8		N	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
H1036	213	0	1	01	01	H1036_213_0	7		N	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	213	0	1	01	01	H1036_213_0	7		N	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	213	0	1	01	01	H1036_213_0	7		N	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		70.00	35.00		35.00
H1036	213	0	1	01	01	H1036_213_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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
H1036	213	0	1	01	01	H1036_213_0	7		N	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
H1036	217	0	1	01	01	H1036_217_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
H1036	217	0	1	01	01	H1036_217_0	4			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	217	0	1	01	01	H1036_217_0	4			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		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	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H1036	217	0	1	01	01	H1036_217_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
H1036	226	0	1	01	01	H1036_226_0	6		N	Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				1.00	24		24																								25		25				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H1036	226	0	1	01	01	H1036_226_0	6		N	Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H1036	226	0	1	01	01	H1036_226_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				60.00	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
H1036	226	0	1	01	01	H1036_226_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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
H1036	226	0	1	01	01	H1036_226_0	6		N	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
H1036	229	0	1	01	01	H1036_229_0	3			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	229	0	1	01	01	H1036_229_0	3			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
H1036	229	0	1	01	01	H1036_229_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	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
H1036	229	0	1	01	01	H1036_229_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										35.00						35.00			35.00			35.00		35.00
H1036	230	0	1	01	01	H1036_230_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	230	0	1	01	01	H1036_230_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																									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	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	230	0	1	01	01	H1036_230_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	35		35																								50		50				35		35			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
H1036	230	0	1	01	01	H1036_230_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	233	0	1	02	01	H1036_233_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
H1036	233	0	1	02	01	H1036_233_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
H1036	233	0	1	02	01	H1036_233_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		95.00	35.00		35.00
H1036	233	0	1	02	01	H1036_233_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H1036	233	0	1	02	01	H1036_233_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
H1036	234	0	1	01	01	H1036_234_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, 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	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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1036	234	0	1	01	01	H1036_234_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	234	0	1	01	01	H1036_234_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	42		42																								42		42				42		42			42			42								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	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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1036	234	0	1	01	01	H1036_234_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	236	0	1	01	01	H1036_236_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
H1036	236	0	1	01	01	H1036_236_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
H1036	236	0	1	01	01	H1036_236_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		95.00	35.00		35.00
H1036	236	0	1	01	01	H1036_236_0	4			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																								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
H1036	236	0	1	01	01	H1036_236_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
H1036	265	1	1	01	01	H1036_265_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
H1036	265	1	1	01	01	H1036_265_1	4			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	265	1	1	01	01	H1036_265_1	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	265	1	1	01	01	H1036_265_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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		105.00	35.00		35.00
H1036	265	1	1	01	01	H1036_265_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
H1036	265	2	1	01	01	H1036_265_2	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
H1036	265	2	1	01	01	H1036_265_2	4			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	265	2	1	01	01	H1036_265_2	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	265	2	1	01	01	H1036_265_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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		105.00	35.00		35.00
H1036	265	2	1	01	01	H1036_265_2	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
H1036	266	0	1	01	01	H1036_266_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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	266	0	1	01	01	H1036_266_0	4			Generic	4	11	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				0.00	0.00	0.00	Preferred Generic, 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	266	0	1	01	01	H1036_266_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									30.00		90.00				30.00		60.00				30.00				30.00		1.00				1.00	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00		90.00				30.00		90.00	30.00		60.00	30.00		30.00
H1036	266	0	1	01	01	H1036_266_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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		105.00	35.00		35.00
H1036	266	0	1	01	01	H1036_266_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
H1036	269	0	1	01	01	H1036_269_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
H1036	269	0	1	01	01	H1036_269_0	4			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	269	0	1	01	01	H1036_269_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	269	0	1	01	01	H1036_269_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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		105.00	35.00		35.00
H1036	269	0	1	01	01	H1036_269_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
H1036	270	0	1	01	01	H1036_270_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
H1036	270	0	1	01	01	H1036_270_0	4			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	270	0	1	01	01	H1036_270_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	41.00		123.00																									47.00		141.00				41.00		82.00				41.00				41.00		1.37				1.57	1.37	1.32	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
H1036	270	0	1	01	01	H1036_270_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	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		35.00
H1036	270	0	1	01	01	H1036_270_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
H1036	271	0	1	01	01	H1036_271_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
H1036	271	0	1	01	01	H1036_271_0	4			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	271	0	1	01	01	H1036_271_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		95.00	35.00		35.00
H1036	271	0	1	01	01	H1036_271_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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
H1036	271	0	1	01	01	H1036_271_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
H1036	278	0	1	01	01	H1036_278_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
H1036	278	0	1	01	01	H1036_278_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
H1036	278	0	1	01	01	H1036_278_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	278	0	1	01	01	H1036_278_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																									95.00		285.00				80.00		160.00				80.00				80.00		2.67				3.17	2.67	2.58	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
H1036	278	0	1	01	01	H1036_278_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	280	0	1	01	01	H1036_280_0	6		N	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	280	0	1	01	01	H1036_280_0	6		N	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	280	0	1	01	01	H1036_280_0	6		N	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		70.00	35.00		35.00
H1036	280	0	1	01	01	H1036_280_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				79.00	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
H1036	280	0	1	01	01	H1036_280_0	6		N	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
H1036	285	0	1	01	01	H1036_285_0	8		N	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	285	0	1	01	01	H1036_285_0	8		N	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	285	0	1	01	01	H1036_285_0	8		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				60.00	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
H1036	285	0	1	01	01	H1036_285_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				79.00	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
H1036	285	0	1	01	01	H1036_285_0	8		N	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
H1036	286	0	1	01	01	H1036_286_0	3			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	286	0	1	01	01	H1036_286_0	3			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
H1036	286	0	1	01	01	H1036_286_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	286	0	1	01	01	H1036_286_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	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		105.00	35.00		35.00
H1036	286	0	1	01	01	H1036_286_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										35.00						35.00			35.00			35.00		35.00
H1036	291	0	1	02	01	H1036_291_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
H1036	291	0	1	02	01	H1036_291_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
H1036	291	0	1	02	01	H1036_291_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		95.00	35.00		35.00
H1036	291	0	1	02	01	H1036_291_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H1036	291	0	1	02	01	H1036_291_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
H1036	292	0	1	01	01	H1036_292_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, Select Care Drugs										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	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, Select Care Drugs										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	4			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		95.00				35.00				35.00		1.17				1.57	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	292	0	1	01	01	H1036_292_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				90.00	50		50																								50		50				50		50			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		35.00
H1036	292	0	1	01	01	H1036_292_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	292	0	1	01	01	H1036_292_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				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	295	0	1	01	01	H1036_295_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
H1036	295	0	1	01	01	H1036_295_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
H1036	295	0	1	01	01	H1036_295_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	295	0	1	01	01	H1036_295_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H1036	295	0	1	01	01	H1036_295_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	297	0	1	01	01	H1036_297_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																									0.00		0.00				0.00		0.00				0.00				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	297	0	1	01	01	H1036_297_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	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
H1036	297	0	1	01	01	H1036_297_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	297	0	1	01	01	H1036_297_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	50		50																								50		50				50		50			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		35.00
H1036	297	0	1	01	01	H1036_297_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	297	0	1	01	01	H1036_297_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				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	298	0	1	01	01	H1036_298_0	3			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, Select Care Drugs										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	3			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, Select Care Drugs										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	3			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		95.00				35.00				35.00		1.17				1.57	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	298	0	1	01	01	H1036_298_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	50		50																								50		50				50		50			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		35.00
H1036	298	0	1	01	01	H1036_298_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1036	298	0	1	01	01	H1036_298_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				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	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, 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	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, 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	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1036	299	0	1	01	01	H1036_299_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	35		35																								50		50				35		35			35			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	299	0	1	01	01	H1036_299_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	299	0	1	01	01	H1036_299_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				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	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, 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	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, 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	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1036	300	0	1	01	01	H1036_300_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				64.00	35		35																								50		50				35		35			35			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	300	0	1	01	01	H1036_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1036	300	0	1	01	01	H1036_300_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				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	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, 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	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, 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	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1036	301	0	1	01	01	H1036_301_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00
H1036	301	0	1	01	01	H1036_301_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	301	0	1	01	01	H1036_301_0	6			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				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	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, 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	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, 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	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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	302	0	1	01	01	H1036_302_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	50		50																								50		50				50		50			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		35.00
H1036	302	0	1	01	01	H1036_302_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	302	0	1	01	01	H1036_302_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				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	304	0	1	01	01	H1036_304_0	7		N	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	304	0	1	01	01	H1036_304_0	7		N	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	304	0	1	01	01	H1036_304_0	7		N	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		70.00	35.00		35.00
H1036	304	0	1	01	01	H1036_304_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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
H1036	304	0	1	01	01	H1036_304_0	7		N	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
H1036	305	0	1	01	01	H1036_305_0	3			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	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	3			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	305	0	1	01	01	H1036_305_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1036	305	0	1	01	01	H1036_305_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				89.00	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		105.00	35.00		35.00
H1036	305	0	1	01	01	H1036_305_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										35.00						35.00			35.00			35.00		35.00
H1036	306	0	1	01	01	H1036_306_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, Select Care Drugs										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	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, Select Care Drugs										10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1036	306	0	1	01	01	H1036_306_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	306	0	1	01	01	H1036_306_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	38		38																								38		38				38		38			38			38								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	306	0	1	01	01	H1036_306_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1036	306	0	1	01	01	H1036_306_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				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	308	0	1	01	01	H1036_308_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
H1036	308	0	1	01	01	H1036_308_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
H1036	308	0	1	01	01	H1036_308_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		121.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		85.00	35.00		35.00
H1036	308	0	1	01	01	H1036_308_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H1036	308	0	1	01	01	H1036_308_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
H1036	310	0	1	01	01	H1036_310_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, 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			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, 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			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				87.00	50		50																								50		50				50		50			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		35.00
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			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				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			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, 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			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, 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			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	50		50																								50		50				50		50			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		35.00
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			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				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			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, 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			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, 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			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		95.00	35.00		35.00
H1036	312	0	1	01	01	H1036_312_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	48		48																								48		48				48		48			48			48								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			Specialty Tier	4	11	1	1	5	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			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				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			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, 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			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, 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			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1036	313	0	1	01	01	H1036_313_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				66.00	35		35																								50		50				35		35			35			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	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			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				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	314	0	1	01	01	H1036_314_0	8		N	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	314	0	1	01	01	H1036_314_0	8		N	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	314	0	1	01	01	H1036_314_0	8		N	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		70.00	35.00		35.00
H1036	314	0	1	01	01	H1036_314_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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
H1036	314	0	1	01	01	H1036_314_0	8		N	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
H1036	315	0	1	01	01	H1036_315_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, 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	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, 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	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		95.00	35.00		35.00
H1036	315	0	1	01	01	H1036_315_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				87.00	50		50																								50		50				50		50			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		35.00
H1036	315	0	1	01	01	H1036_315_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	315	0	1	01	01	H1036_315_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				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	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, 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	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, 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	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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	316	0	1	01	01	H1036_316_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	50		50																								50		50				50		50			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		35.00
H1036	316	0	1	01	01	H1036_316_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	316	0	1	01	01	H1036_316_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				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	317	0	1	01	01	H1036_317_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	317	0	1	01	01	H1036_317_0	4			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
H1036	317	0	1	01	01	H1036_317_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	317	0	1	01	01	H1036_317_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	317	0	1	01	01	H1036_317_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1036	317	0	1	01	01	H1036_317_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				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	318	0	1	02	01	H1036_318_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
H1036	318	0	1	02	01	H1036_318_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
H1036	318	0	1	02	01	H1036_318_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		95.00	35.00		35.00
H1036	318	0	1	02	01	H1036_318_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H1036	318	0	1	02	01	H1036_318_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
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	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	1	110		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 Drug, Specialty Tier																								
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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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	010		01	010		1	30						2	2	30						30		31	40.00																					40.00																		40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						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				276.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
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			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			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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				252.00	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
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	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	1	110		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 Drug, Specialty Tier																								
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																3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										3.00		9.00						9.00				3.00		3.00
H1045	018	0	1	01	01	H1045_018_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30						2	2	30						30		31	45.00																					45.00																		45.00				45.00		1.50			1.5			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						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				256.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H1045	025	0	1	02	01	H1045_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																								
H1045	025	0	1	02	01	H1045_025_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																								
H1045	025	0	1	02	01	H1045_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
H1045	025	0	1	02	01	H1045_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	025	0	1	02	01	H1045_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				203.00	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
H1045	026	0	1	02	01	H1045_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																								
H1045	026	0	1	02	01	H1045_026_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																								
H1045	026	0	1	02	01	H1045_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
H1045	026	0	1	02	01	H1045_026_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	026	0	1	02	01	H1045_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
H1045	028	0	1	02	01	H1045_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																								
H1045	028	0	1	02	01	H1045_028_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																								
H1045	028	0	1	02	01	H1045_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
H1045	028	0	1	02	01	H1045_028_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	028	0	1	02	01	H1045_028_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				194.00	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
H1045	030	0	1	02	01	H1045_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																								
H1045	030	0	1	02	01	H1045_030_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																								
H1045	030	0	1	02	01	H1045_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
H1045	030	0	1	02	01	H1045_030_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	030	0	1	02	01	H1045_030_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				204.00	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
H1045	031	0	1	02	01	H1045_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																								
H1045	031	0	1	02	01	H1045_031_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																								
H1045	031	0	1	02	01	H1045_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
H1045	031	0	1	02	01	H1045_031_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	031	0	1	02	01	H1045_031_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				208.00	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
H1045	033	0	1	02	01	H1045_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																								
H1045	033	0	1	02	01	H1045_033_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																								
H1045	033	0	1	02	01	H1045_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
H1045	033	0	1	02	01	H1045_033_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	033	0	1	02	01	H1045_033_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H1045	034	0	1	02	01	H1045_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																								
H1045	034	0	1	02	01	H1045_034_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																								
H1045	034	0	1	02	01	H1045_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
H1045	034	0	1	02	01	H1045_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	034	0	1	02	01	H1045_034_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				229.00	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
H1045	036	0	1	02	01	H1045_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																								
H1045	036	0	1	02	01	H1045_036_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																								
H1045	036	0	1	02	01	H1045_036_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
H1045	036	0	1	02	01	H1045_036_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	036	0	1	02	01	H1045_036_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				218.00	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
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			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			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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				208.00	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
H1045	041	0	1	02	01	H1045_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																								
H1045	041	0	1	02	01	H1045_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																								
H1045	041	0	1	02	01	H1045_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
H1045	041	0	1	02	01	H1045_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	041	0	1	02	01	H1045_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				190.00	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
H1045	042	0	1	02	01	H1045_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																								
H1045	042	0	1	02	01	H1045_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																								
H1045	042	0	1	02	01	H1045_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
H1045	042	0	1	02	01	H1045_042_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	042	0	1	02	01	H1045_042_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				204.00	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
H1045	043	0	1	02	01	H1045_043_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H1045	043	0	1	02	01	H1045_043_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
H1045	043	0	1	02	01	H1045_043_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	043	0	1	02	01	H1045_043_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				181.00	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
H1045	045	0	1	02	01	H1045_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																								
H1045	045	0	1	02	01	H1045_045_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																								
H1045	045	0	1	02	01	H1045_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
H1045	045	0	1	02	01	H1045_045_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	045	0	1	02	01	H1045_045_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				212.00	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
H1045	048	1	1	02	01	H1045_048_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																								
H1045	048	1	1	02	01	H1045_048_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																								
H1045	048	1	1	02	01	H1045_048_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										25.00		75.00						75.00			65.00	25.00		25.00
H1045	048	1	1	02	01	H1045_048_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	048	1	1	02	01	H1045_048_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H1045	048	2	1	02	01	H1045_048_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																								
H1045	048	2	1	02	01	H1045_048_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																								
H1045	048	2	1	02	01	H1045_048_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										25.00		75.00						75.00			65.00	25.00		25.00
H1045	048	2	1	02	01	H1045_048_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	048	2	1	02	01	H1045_048_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H1045	048	3	1	02	01	H1045_048_3	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	048	3	1	02	01	H1045_048_3	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																								
H1045	048	3	1	02	01	H1045_048_3	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
H1045	048	3	1	02	01	H1045_048_3	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	048	3	1	02	01	H1045_048_3	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H1045	048	4	1	02	01	H1045_048_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																								
H1045	048	4	1	02	01	H1045_048_4	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																								
H1045	048	4	1	02	01	H1045_048_4	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
H1045	048	4	1	02	01	H1045_048_4	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	048	4	1	02	01	H1045_048_4	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H1045	055	0	1	02	01	H1045_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																								
H1045	055	0	1	02	01	H1045_055_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																								
H1045	055	0	1	02	01	H1045_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
H1045	055	0	1	02	01	H1045_055_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	055	0	1	02	01	H1045_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				190.00	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
H1045	056	0	1	02	01	H1045_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																								
H1045	056	0	1	02	01	H1045_056_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																								
H1045	056	0	1	02	01	H1045_056_0	5			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	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	90.00																											90.00						90.00						90.00				90.00		3.00				3.00	3.00	2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	056	0	1	02	01	H1045_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				219.00	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
H1045	057	0	1	02	01	H1045_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																								
H1045	057	0	1	02	01	H1045_057_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																								
H1045	057	0	1	02	01	H1045_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
H1045	057	0	1	02	01	H1045_057_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	057	0	1	02	01	H1045_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H1045	058	0	1	02	01	H1045_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																								
H1045	058	0	1	02	01	H1045_058_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																								
H1045	058	0	1	02	01	H1045_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
H1045	058	0	1	02	01	H1045_058_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	058	0	1	02	01	H1045_058_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H1045	059	0	1	02	01	H1045_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																								
H1045	059	0	1	02	01	H1045_059_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																								
H1045	059	0	1	02	01	H1045_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
H1045	059	0	1	02	01	H1045_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	059	0	1	02	01	H1045_059_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				182.00	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
H1045	060	0	1	02	01	H1045_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																								
H1045	060	0	1	02	01	H1045_060_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																								
H1045	060	0	1	02	01	H1045_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
H1045	060	0	1	02	01	H1045_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	060	0	1	02	01	H1045_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				188.00	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
H1045	067	0	1	02	01	H1045_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																								
H1045	067	0	1	02	01	H1045_067_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																								
H1045	067	0	1	02	01	H1045_067_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
H1045	067	0	1	02	01	H1045_067_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	067	0	1	02	01	H1045_067_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
H1045	069	0	1	02	01	H1045_069_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	069	0	1	02	01	H1045_069_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																								
H1045	069	0	1	02	01	H1045_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																											141.00						131.00				47.00				47.00		1.56						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	069	0	1	02	01	H1045_069_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1045	069	0	1	02	01	H1045_069_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
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			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			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					42.00	84.00	126.00							117.50																47.00				47.00			1.57	1.4				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	001	0	1	02	01	H1099_001_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
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											2379.46	33						2379.46	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			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								47.00	94.00	141.00					42.00	84.00	126.00							117.50																47.00				47.00			1.57	1.4				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	006	0	1	01	01	H1099_006_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
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											2379.46	33						2379.46	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			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								47.00	94.00	141.00					42.00	84.00	126.00							117.50																47.00				47.00			1.57	1.4				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	014	0	1	01	01	H1099_014_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
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											2379.46	33						2379.46	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	3			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	3			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	3			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					42.00	84.00	126.00							117.50																47.00				47.00			1.57	1.4				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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
H1099	016	0	1	01	01	H1099_016_0	3			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2379.46	33						2379.46	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00									35.00		35.00
H1099	023	0	1	01	01	H1099_023_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	023	0	1	01	01	H1099_023_0	4			Generic	4	11	1	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					2.50	5.00	7.50							0.00																5.00				5.00			0.17	0.08				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1099	023	0	1	01	01	H1099_023_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					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										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	023	0	1	01	01	H1099_023_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
H1099	023	0	1	01	01	H1099_023_0	4			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2379.46	33						2379.46	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00									35.00		35.00
H1099	024	0	1	01	01	H1099_024_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	024	0	1	01	01	H1099_024_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	024	0	1	01	01	H1099_024_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					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										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	024	0	1	01	01	H1099_024_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
H1099	024	0	1	01	01	H1099_024_0	4			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2379.46	31						2379.46	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00									35.00		35.00
H1099	025	0	1	02	01	H1099_025_0	3			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	025	0	1	02	01	H1099_025_0	3			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	025	0	1	02	01	H1099_025_0	3			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					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										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	025	0	1	02	01	H1099_025_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
H1099	025	0	1	02	01	H1099_025_0	3			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2379.46	30						2379.46	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00									35.00		35.00
H1099	026	0	1	01	01	H1099_026_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	026	0	1	01	01	H1099_026_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	026	0	1	01	01	H1099_026_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					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										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	026	0	1	01	01	H1099_026_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
H1099	026	0	1	01	01	H1099_026_0	4			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2379.46	28						2379.46	28																							28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00									35.00		35.00
H1099	027	0	1	02	01	H1099_027_0	3			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	027	0	1	02	01	H1099_027_0	3			Generic	4	11	1	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								15.00	30.00	45.00					7.50	15.00	22.50							0.00																15.00				15.00			0.50	0.25				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1099	027	0	1	02	01	H1099_027_0	3			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					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										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	027	0	1	02	01	H1099_027_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											88.41	25	25	25				88.41	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			105.00				35.00		35.00
H1099	027	0	1	02	01	H1099_027_0	3			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2379.46	30						2379.46	30																							30			30								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	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1109	005	0	1	01	01	H1109_005_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1109	005	0	1	01	01	H1109_005_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.88	24	24	24				111.59	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
H1109	005	0	1	01	01	H1109_005_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											47.92	25	25	25				38.32	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
H1109	005	0	1	01	01	H1109_005_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											882.11	25						807.76	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
H1112	038	0	1	02	01	H1112_038_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																								
H1112	038	0	1	02	01	H1112_038_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1112	038	0	1	02	01	H1112_038_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.21	25	25	25				153.21	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
H1112	038	0	1	02	01	H1112_038_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											59.44	33	33	33				57.64	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	02	01	H1112_038_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, Select Care Drugs																								
H1112	038	0	1	02	01	H1112_038_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																								
H1112	039	0	1	02	01	H1112_039_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																								
H1112	039	0	1	02	01	H1112_039_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1112	039	0	1	02	01	H1112_039_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.64	25	25	25				159.64	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
H1112	039	0	1	02	01	H1112_039_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											42.80	35	35	35				42.80	35	35	35										35	35	35				35	35	35			35			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
H1112	039	0	1	02	01	H1112_039_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, Select Care Drugs																								
H1112	039	0	1	02	01	H1112_039_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																								
H1112	042	0	1	02	01	H1112_042_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																								
H1112	042	0	1	02	01	H1112_042_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1112	042	0	1	02	01	H1112_042_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.52	25	25	25				159.52	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
H1112	042	0	1	02	01	H1112_042_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											59.80	40	40	40				58.31	39	39	39										40	40	40				39	39	39			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
H1112	042	0	1	02	01	H1112_042_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, Select Care Drugs																								
H1112	042	0	1	02	01	H1112_042_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																								
H1112	043	0	1	02	01	H1112_043_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1112	043	0	1	02	01	H1112_043_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1112	043	0	1	02	01	H1112_043_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											123.02	20	20	20				123.02	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
H1112	043	0	1	02	01	H1112_043_0	6			Non-Preferred Drug	3	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	200.00				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
H1112	043	0	1	02	01	H1112_043_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																								
H1112	043	0	1	02	01	H1112_043_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																								
H1112	044	0	1	02	01	H1112_044_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																								
H1112	044	0	1	02	01	H1112_044_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1112	044	0	1	02	01	H1112_044_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											163.93	25	25	25				163.93	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
H1112	044	0	1	02	01	H1112_044_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											45.79	39	39	39				45.79	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
H1112	044	0	1	02	01	H1112_044_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, Select Care Drugs																								
H1112	044	0	1	02	01	H1112_044_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																								
H1170	002	0	1	01	01	H1170_002_0	12			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	002	0	1	01	01	H1170_002_0	12			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	002	0	1	01	01	H1170_002_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																			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										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	12			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										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	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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	12			Vaccines	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																								
H1170	008	0	1	01	01	H1170_008_0	12		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	008	0	1	01	01	H1170_008_0	12		N	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																			0.00	0.00	0.00																7.00				7.00		0.23			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	12		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	008	0	1	01	01	H1170_008_0	12		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	008	0	1	01	01	H1170_008_0	12		N	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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	12		N	Vaccines	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																								
H1170	009	0	1	01	01	H1170_009_0	12			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	009	0	1	01	01	H1170_009_0	12			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	009	0	1	01	01	H1170_009_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																			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										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	12			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										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	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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	12			Vaccines	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																								
H1170	011	0	1	01	01	H1170_011_0	11		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	011	0	1	01	01	H1170_011_0	11		N	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	011	0	1	01	01	H1170_011_0	11		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										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	11		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										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	11		N	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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	11		N	Vaccines	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																								
H1170	012	0	1	01	01	H1170_012_0	11			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	012	0	1	01	01	H1170_012_0	11			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										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	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																			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										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	11			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										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	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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	11			Vaccines	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																								
H1170	013	0	1	02	01	H1170_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	0.00	0.00	0.00																			0.00	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	013	0	1	02	01	H1170_013_0	11			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	013	0	1	02	01	H1170_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																			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										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	11			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										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	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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	11			Vaccines	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																								
H1170	015	0	1	01	01	H1170_015_0	11		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	015	0	1	01	01	H1170_015_0	11		N	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																			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	015	0	1	01	01	H1170_015_0	11		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	015	0	1	01	01	H1170_015_0	11		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	015	0	1	01	01	H1170_015_0	11		N	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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	015	0	1	01	01	H1170_015_0	11		N	Vaccines	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																								
H1189	002	0	1	01	01	H1189_002_0	6			Preferred Generic	4	01	1	2	1	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	6			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	5.00		15.00																					0.00																5.00				5.00		0.17						0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1189	002	0	1	01	01	H1189_002_0	6			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	6			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										35.00		105.00						105.00				35.00		35.00
H1189	002	0	1	01	01	H1189_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				725.27	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	6			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	6			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	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	6			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	5.00		15.00																					0.00																5.00				5.00		0.17						0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1189	003	0	1	01	01	H1189_003_0	6			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	6			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										35.00		105.00						105.00				35.00		35.00
H1189	003	0	1	01	01	H1189_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				809.64	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	6			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	6			Preferred Generic	4	01	1	2	1	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	6			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	5.00		15.00																					0.00																5.00				5.00		0.17						0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1189	004	0	1	01	01	H1189_004_0	6			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	6			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										35.00		105.00						105.00				35.00		35.00
H1189	004	0	1	01	01	H1189_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				767.16	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	6			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	6			Preferred Generic	4	01	1	2	1	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	6			Generic	4	01	1	2	2	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	6			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	6			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										35.00		105.00						105.00				35.00		35.00
H1189	005	0	1	01	01	H1189_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				991.87	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	6			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	6			Preferred Generic	4	01	1	2	1	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	6			Generic	4	01	1	2	2	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	6			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	6			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										35.00		105.00						105.00				35.00		35.00
H1189	009	0	1	01	01	H1189_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				1024.41	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	6			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	6			Preferred Generic	4	01	1	2	1	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	6			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	5.00		15.00																					0.00																5.00				5.00		0.17						0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1189	010	0	1	01	01	H1189_010_0	6			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	6			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										35.00		105.00						105.00				35.00		35.00
H1189	010	0	1	01	01	H1189_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				893.92	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	6			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																								
H1206	002	0	1	02	01	H1206_002_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1206	002	0	1	02	01	H1206_002_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1206	002	0	1	02	01	H1206_002_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.62	24	24	24				102.81	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
H1206	002	0	1	02	01	H1206_002_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.15	25	25	25				33.70	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
H1206	002	0	1	02	01	H1206_002_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											793.96	25						782.31	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
H1206	003	0	1	02	01	H1206_003_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1206	003	0	1	02	01	H1206_003_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1206	003	0	1	02	01	H1206_003_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.08	22	22	22				38.42	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	003	0	1	02	01	H1206_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.76	25	25	25				43.03	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
H1206	003	0	1	02	01	H1206_003_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											331.56	25						293.48	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
H1206	004	0	1	01	01	H1206_004_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1206	004	0	1	01	01	H1206_004_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1206	004	0	1	01	01	H1206_004_0	2			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	004	0	1	01	01	H1206_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.19	50	50	50				54.63	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
H1206	004	0	1	01	01	H1206_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											951.69	29						920.26	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
H1215	001	0	1	02	01	H1215_001_0	5		N	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					5.00	10.00	15.00											19.00	38.00	57.00				5.00	10.00	0.00				19.00				19.00			0.63	0.17		0.63	0.17	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1215	001	0	1	02	01	H1215_001_0	5		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					18.00	36.00	54.00											20.00	40.00	60.00				18.00	36.00	0.00				20.00				20.00			0.67	0.6		0.67	0.6	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1215	001	0	1	02	01	H1215_001_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											111.67	20	20	20				111.67	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
H1215	001	0	1	02	01	H1215_001_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											35.20	37	37	37				35.20	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
H1215	001	0	1	02	01	H1215_001_0	5		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, Select Care Drugs																								
H1215	001	0	1	02	01	H1215_001_0	5		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	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	02	01	H1215_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1215	003	0	1	02	01	H1215_003_0	5			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																								
H1215	003	0	1	02	01	H1215_003_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.08	25	25	25				164.08	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
H1215	003	0	1	02	01	H1215_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											50.08	31	31	31				50.08	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
H1215	003	0	1	02	01	H1215_003_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, Select Care Drugs																								
H1215	003	0	1	02	01	H1215_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																								
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			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	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.75	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	52.50	70.00				35.00		35.00
H1225	001	0	1	01	01	H1225_001_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				74.16	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	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				1032.45	25																				25																	25			25								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	10			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										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	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																			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										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	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	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H1230	003	0	1	01	01	H1230_003_0	10			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										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	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																			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										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	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	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H1230	008	0	1	01	01	H1230_008_0	9		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1230	008	0	1	01	01	H1230_008_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				1.00	4	4	4																		0	0	0															4			4								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1230	008	0	1	01	01	H1230_008_0	9		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				74.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	008	0	1	01	01	H1230_008_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				112.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	008	0	1	01	01	H1230_008_0	9		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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	008	0	1	01	01	H1230_008_0	9		N	Vaccines	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																								
H1230	013	0	1	01	01	H1230_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	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										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	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																			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										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	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	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H1230	014	0	1	01	01	H1230_014_0	10			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										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	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																			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										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	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	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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										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	10			Vaccines	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																								
H1248	004	0	1	04	01	H1248_004_0	5			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	5			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	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					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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.91	50	50	50				44.16	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
H1248	004	0	1	04	01	H1248_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1374.56	33						792.72	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1248	007	0	1	04	01	H1248_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								10.00	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	5			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	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					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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.90	50	50	50				60.85	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
H1248	007	0	1	04	01	H1248_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1053.51	29						595.67	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1277	001	0	1	02	01	H1277_001_0	6			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	6			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	6			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	6			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
H1277	001	0	1	02	01	H1277_001_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31					25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H1278	003	0	1	04	01	H1278_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																								
H1278	003	0	1	04	01	H1278_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																								
H1278	003	0	1	04	01	H1278_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
H1278	003	0	1	04	01	H1278_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1278	003	0	1	04	01	H1278_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				194.00	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
H1278	004	0	1	04	01	H1278_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																								
H1278	004	0	1	04	01	H1278_004_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	004	0	1	04	01	H1278_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
H1278	004	0	1	04	01	H1278_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1278	004	0	1	04	01	H1278_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				200.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				186.00	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
H1278	007	0	1	04	01	H1278_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																								
H1278	007	0	1	04	01	H1278_007_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	007	0	1	04	01	H1278_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
H1278	007	0	1	04	01	H1278_007_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1278	007	0	1	04	01	H1278_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				158.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				164.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				227.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				181.00	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
H1278	014	0	1	04	01	H1278_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																								
H1278	014	0	1	04	01	H1278_014_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	014	0	1	04	01	H1278_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
H1278	014	0	1	04	01	H1278_014_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1278	014	0	1	04	01	H1278_014_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				171.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				192.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				174.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				201.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				206.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				175.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				192.00	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
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			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	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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	028	0	1	04	01	H1278_028_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				147.00	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
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			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	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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	029	0	1	04	01	H1278_029_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				174.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	030	0	1	04	01	H1278_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				162.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	032	0	1	04	01	H1278_032_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				198.00	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
H1280	001	0	1	01	01	H1280_001_0	8			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1280	001	0	1	01	01	H1280_001_0	8			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H1280	001	0	1	01	01	H1280_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																			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
H1280	001	0	1	01	01	H1280_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				97.04	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	70.00				35.00		35.00
H1280	001	0	1	01	01	H1280_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				695.93	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H1290	001	0	1	01	01	H1290_001_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				113.00	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	001	0	1	01	01	H1290_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				48.00	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	001	0	1	01	01	H1290_001_0	7			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	002	0	1	01	01	H1290_002_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
H1290	002	0	1	01	01	H1290_002_0	8			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	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				112.00	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	002	0	1	01	01	H1290_002_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				44.00	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	002	0	1	01	01	H1290_002_0	8			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	003	0	1	01	01	H1290_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
H1290	003	0	1	01	01	H1290_003_0	8			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	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				114.00	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	003	0	1	01	01	H1290_003_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				37.00	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	003	0	1	01	01	H1290_003_0	8			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	005	0	1	01	01	H1290_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				112.00	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	005	0	1	01	01	H1290_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				36.00	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	005	0	1	01	01	H1290_005_0	7			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	013	0	1	01	01	H1290_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										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	7			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	013	0	1	01	01	H1290_013_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				114.00	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	013	0	1	01	01	H1290_013_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				43.00	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	013	0	1	01	01	H1290_013_0	7			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	014	0	1	01	01	H1290_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				113.00	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	014	0	1	01	01	H1290_014_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				39.00	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	014	0	1	01	01	H1290_014_0	7			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	015	0	1	01	01	H1290_015_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				113.00	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	015	0	1	01	01	H1290_015_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				43.00	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	015	0	1	01	01	H1290_015_0	7			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	018	0	1	01	01	H1290_018_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				116.00	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	018	0	1	01	01	H1290_018_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				47.00	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	018	0	1	01	01	H1290_018_0	7			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	019	0	1	01	01	H1290_019_0	10		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	10		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	10		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	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					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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	019	0	1	01	01	H1290_019_0	10		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	10		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	10		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	10		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	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					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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	020	0	1	01	01	H1290_020_0	10		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	11		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	11		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	11		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	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					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	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										35.00						35.00						35.00		35.00
H1290	021	0	1	01	01	H1290_021_0	11		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	8		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	8		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	8		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	8		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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	022	0	1	01	01	H1290_022_0	8		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	8		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	8		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	8		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	8		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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	023	0	1	01	01	H1290_023_0	8		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	8		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	8		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	8		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	8		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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	024	0	1	01	01	H1290_024_0	8		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	025	0	1	01	01	H1290_025_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	025	0	1	01	01	H1290_025_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	025	0	1	01	01	H1290_025_0	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				109.00	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	025	0	1	01	01	H1290_025_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				36.00	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	025	0	1	01	01	H1290_025_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
H1290	027	0	1	01	01	H1290_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										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	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	027	0	1	01	01	H1290_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				109.00	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	027	0	1	01	01	H1290_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				31.00	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	027	0	1	01	01	H1290_027_0	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	029	0	1	01	01	H1290_029_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
H1290	029	0	1	01	01	H1290_029_0	8			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	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				107.00	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	029	0	1	01	01	H1290_029_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				33.00	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	029	0	1	01	01	H1290_029_0	8			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	031	0	1	01	01	H1290_031_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
H1290	031	0	1	01	01	H1290_031_0	5			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H1290	031	0	1	01	01	H1290_031_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				112.00	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	031	0	1	01	01	H1290_031_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				35.00	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	031	0	1	01	01	H1290_031_0	5			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	032	0	1	01	01	H1290_032_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
H1290	032	0	1	01	01	H1290_032_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																			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	032	0	1	01	01	H1290_032_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				112.00	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	032	0	1	01	01	H1290_032_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				38.00	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	032	0	1	01	01	H1290_032_0	8			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	033	0	1	01	01	H1290_033_0	10		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	10		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	10		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	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					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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	033	0	1	01	01	H1290_033_0	10		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	11		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	11		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	11		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	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					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	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										35.00						35.00						35.00		35.00
H1290	034	0	1	01	01	H1290_034_0	11		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	035	0	1	01	01	H1290_035_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										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	7			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	035	0	1	01	01	H1290_035_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				110.00	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	035	0	1	01	01	H1290_035_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				35.00	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	035	0	1	01	01	H1290_035_0	7			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	036	1	1	01	01	H1290_036_1	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				111.00	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	036	1	1	01	01	H1290_036_1	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				35.00	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	036	1	1	01	01	H1290_036_1	7			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	036	2	1	01	01	H1290_036_2	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				111.00	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	036	2	1	01	01	H1290_036_2	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				35.00	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	036	2	1	01	01	H1290_036_2	7			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	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			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			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				102.00	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				48.00	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			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			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				102.00	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				48.00	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			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			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				102.00	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				48.00	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	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
H1290	037	4	1	01	01	H1290_037_4	8			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	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				102.00	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	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				48.00	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	8			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	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
H1290	037	5	1	01	01	H1290_037_5	8			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	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				102.00	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	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				48.00	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	8			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	11		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	11		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	11		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	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					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	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										35.00						35.00						35.00		35.00
H1290	039	0	1	01	01	H1290_039_0	11		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	10		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	10		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	10		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	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					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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	041	0	1	01	01	H1290_041_0	10		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	044	1	1	01	01	H1290_044_1	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	044	1	1	01	01	H1290_044_1	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	044	1	1	01	01	H1290_044_1	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				106.00	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	044	1	1	01	01	H1290_044_1	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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	044	1	1	01	01	H1290_044_1	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	044	2	1	01	01	H1290_044_2	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	044	2	1	01	01	H1290_044_2	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	044	2	1	01	01	H1290_044_2	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				106.00	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	044	2	1	01	01	H1290_044_2	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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	044	2	1	01	01	H1290_044_2	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	044	3	1	01	01	H1290_044_3	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	3	1	01	01	H1290_044_3	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	3	1	01	01	H1290_044_3	11			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				106.00	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	044	3	1	01	01	H1290_044_3	11			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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	044	3	1	01	01	H1290_044_3	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
H1290	045	0	1	01	01	H1290_045_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										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	7			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	045	0	1	01	01	H1290_045_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				110.00	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	045	0	1	01	01	H1290_045_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				37.00	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	045	0	1	01	01	H1290_045_0	7			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	046	0	1	01	01	H1290_046_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				109.00	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	046	0	1	01	01	H1290_046_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				36.00	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	046	0	1	01	01	H1290_046_0	7			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	049	0	1	01	01	H1290_049_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				118.00	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	049	0	1	01	01	H1290_049_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				41.00	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	049	0	1	01	01	H1290_049_0	7			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	050	0	1	01	01	H1290_050_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				106.00	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	050	0	1	01	01	H1290_050_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				37.00	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	050	0	1	01	01	H1290_050_0	7			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	051	1	1	01	01	H1290_051_1	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										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	7			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
H1290	051	1	1	01	01	H1290_051_1	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				116.00	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	051	1	1	01	01	H1290_051_1	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				41.00	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	051	1	1	01	01	H1290_051_1	7			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	051	2	1	01	01	H1290_051_2	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										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	7			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
H1290	051	2	1	01	01	H1290_051_2	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				116.00	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	051	2	1	01	01	H1290_051_2	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				41.00	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	051	2	1	01	01	H1290_051_2	7			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	052	0	1	01	01	H1290_052_0	7		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	7		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	7		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	7		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	7		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	7		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	053	0	1	01	01	H1290_053_0	8		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	053	0	1	01	01	H1290_053_0	8		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	053	0	1	01	01	H1290_053_0	8		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	053	0	1	01	01	H1290_053_0	8		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	053	0	1	01	01	H1290_053_0	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	053	0	1	01	01	H1290_053_0	8		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	054	0	1	01	01	H1290_054_0	7		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	054	0	1	01	01	H1290_054_0	7		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	054	0	1	01	01	H1290_054_0	7		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	054	0	1	01	01	H1290_054_0	7		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	054	0	1	01	01	H1290_054_0	7		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	054	0	1	01	01	H1290_054_0	7		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	055	0	1	01	01	H1290_055_0	8		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	055	0	1	01	01	H1290_055_0	8		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	055	0	1	01	01	H1290_055_0	8		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	055	0	1	01	01	H1290_055_0	8		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	055	0	1	01	01	H1290_055_0	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H1290	055	0	1	01	01	H1290_055_0	8		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	056	0	1	01	01	H1290_056_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	056	0	1	01	01	H1290_056_0	7			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	056	0	1	01	01	H1290_056_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	056	0	1	01	01	H1290_056_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				42.00	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	056	0	1	01	01	H1290_056_0	7			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	057	0	1	01	01	H1290_057_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	057	0	1	01	01	H1290_057_0	7			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	057	0	1	01	01	H1290_057_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	057	0	1	01	01	H1290_057_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				42.00	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	057	0	1	01	01	H1290_057_0	7			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	058	0	1	01	01	H1290_058_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	058	0	1	01	01	H1290_058_0	7			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	058	0	1	01	01	H1290_058_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	058	0	1	01	01	H1290_058_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				42.00	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	058	0	1	01	01	H1290_058_0	7			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	059	0	1	01	01	H1290_059_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	059	0	1	01	01	H1290_059_0	7			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	059	0	1	01	01	H1290_059_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	059	0	1	01	01	H1290_059_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				42.00	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	059	0	1	01	01	H1290_059_0	7			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	060	0	1	01	01	H1290_060_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	060	0	1	01	01	H1290_060_0	7			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	060	0	1	01	01	H1290_060_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	060	0	1	01	01	H1290_060_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				42.00	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	060	0	1	01	01	H1290_060_0	7			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	061	0	1	01	01	H1290_061_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	061	0	1	01	01	H1290_061_0	7			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	061	0	1	01	01	H1290_061_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	061	0	1	01	01	H1290_061_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				42.00	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	061	0	1	01	01	H1290_061_0	7			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	062	0	1	01	01	H1290_062_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	062	0	1	01	01	H1290_062_0	7			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	062	0	1	01	01	H1290_062_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	062	0	1	01	01	H1290_062_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				42.00	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	062	0	1	01	01	H1290_062_0	7			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	063	0	1	01	01	H1290_063_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	063	0	1	01	01	H1290_063_0	7			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	063	0	1	01	01	H1290_063_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	063	0	1	01	01	H1290_063_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				42.00	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	063	0	1	01	01	H1290_063_0	7			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	064	0	1	01	01	H1290_064_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	064	0	1	01	01	H1290_064_0	7			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	064	0	1	01	01	H1290_064_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	064	0	1	01	01	H1290_064_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				42.00	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	064	0	1	01	01	H1290_064_0	7			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	065	0	1	01	01	H1290_065_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	065	0	1	01	01	H1290_065_0	7			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	065	0	1	01	01	H1290_065_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	065	0	1	01	01	H1290_065_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				42.00	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	065	0	1	01	01	H1290_065_0	7			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	066	0	1	01	01	H1290_066_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	066	0	1	01	01	H1290_066_0	7			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	066	0	1	01	01	H1290_066_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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	066	0	1	01	01	H1290_066_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				42.00	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	066	0	1	01	01	H1290_066_0	7			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
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								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
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								13.00	26.00	26.00					7.00	14.00	14.00											13.00	26.00	26.00				7.00	14.00	14.00				13.00				13.00			0.43	0.23		0.43	0.23	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	7.00	14.00	14.00	13.00	26.00	26.00	7.00	14.00	14.00	13.00		13.00
H1304	004	0	1	04	01	H1304_004_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											59.75	25	25	25				59.75	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H1304	004	0	1	04	01	H1304_004_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											80.61	43	43	43				80.61	40	40	40										43	43	43				40	40	40			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
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											1094.72	33						1094.72	33												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								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
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								13.00	26.00	39.00					7.00	14.00	21.00											13.00	26.00	39.00				7.00	14.00	0.00				13.00				13.00			0.43	0.23		0.43	0.23	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	39.00	7.00	14.00	21.00	13.00	26.00	39.00	7.00	14.00	0.00	13.00		13.00
H1304	011	1	1	04	01	H1304_011_1	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											49.92	25	25	25				49.92	22	22	22										25	25	25				22	22	22			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
H1304	011	1	1	04	01	H1304_011_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											60.39	43	43	43				60.39	40	40	40										43	43	43				40	40	40			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
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											771.20	30						771.20	30												30						30					30			30								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								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
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								13.00	26.00	39.00					7.00	14.00	21.00											13.00	26.00	39.00				7.00	14.00	0.00				13.00				13.00			0.43	0.23		0.43	0.23	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	39.00	7.00	14.00	21.00	13.00	26.00	39.00	7.00	14.00	0.00	13.00		13.00
H1304	011	2	1	04	01	H1304_011_2	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											49.92	25	25	25				49.92	22	22	22										25	25	25				22	22	22			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
H1304	011	2	1	04	01	H1304_011_2	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											60.39	43	43	43				60.39	40	40	40										43	43	43				40	40	40			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
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											771.20	30						771.20	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1304	013	0	1	04	01	H1304_013_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H1304	013	0	1	04	01	H1304_013_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					7.00	14.00	14.00											13.00	26.00	26.00				7.00	14.00	14.00				13.00				13.00			0.43	0.23		0.43	0.23	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	7.00	14.00	14.00	13.00	26.00	26.00	7.00	14.00	14.00	13.00		13.00
H1304	013	0	1	04	01	H1304_013_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.15	25	25	25				52.15	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H1304	013	0	1	04	01	H1304_013_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											53.21	43	43	43				53.21	40	40	40										43	43	43				40	40	40			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
H1304	013	0	1	04	01	H1304_013_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											677.73	30						677.73	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1339	001	0	1	01	01	H1339_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
H1339	001	0	1	01	01	H1339_001_0	9			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	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				74.62	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	52.50	70.00				35.00		35.00
H1339	001	0	1	01	01	H1339_001_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				74.00	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	52.50	70.00				35.00		35.00
H1339	001	0	1	01	01	H1339_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1009.10	25																				25																	25			25								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	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	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	4			Generic	4	01	1	2	2	1		110	01		110	1				30		100	1	2				30		100	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	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					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	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					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	4			Specialty Tier	4	10	1	1	5	1		110	01		110	1				30		100	1	2				30		100	30		31											459.28	33		33				472.92	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		100	1	2				30		100	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			Generic	4	01	1	2	2	1		110	01		110	1				30		100	1	2				30		100	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			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	2				30		100	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			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					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			Specialty Tier	4	10	1	1	5	1		110	01		110	1				30		100	1	2				30		100	30		31											446.85	33		33				446.86	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		100	1	2				30		100	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			Generic	4	01	1	2	2	1		110	01		110	1				30		100	1	2				30		100	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			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	2				30		100	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			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					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			Specialty Tier	4	10	1	1	5	1		110	01		110	1				30		100	1	2				30		100	30		31											408.18	33		33				402.55	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	6			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	023	1	1	01	01	H1350_023_1	6			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 Drug, Specialty Tier, Select Care Drugs																								
H1350	023	1	1	01	01	H1350_023_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																			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	023	1	1	01	01	H1350_023_1	6			Non-Preferred Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				39.33	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	70.00				35.00		35.00
H1350	023	1	1	01	01	H1350_023_1	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				181.92	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	023	1	1	01	01	H1350_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	023	2	1	01	01	H1350_023_2	6			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	023	2	1	01	01	H1350_023_2	6			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 Drug, Specialty Tier, Select Care Drugs																								
H1350	023	2	1	01	01	H1350_023_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																			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	023	2	1	01	01	H1350_023_2	6			Non-Preferred Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				39.33	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	70.00				35.00		35.00
H1350	023	2	1	01	01	H1350_023_2	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				181.92	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	023	2	1	01	01	H1350_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	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 Drug, 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 Drug, Specialty Tier, Select Care Drugs																								
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 Drug, 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 Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				46.51	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	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				247.34	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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 Drug, 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 Drug, 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 Drug, Specialty Tier, Select Care Drugs																								
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 Drug, 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 Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				46.51	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	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				247.34	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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 Drug, 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 Drug, 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 Drug, Specialty Tier, Select Care Drugs																								
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 Drug, 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 Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				46.51	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	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				247.34	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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 Drug, Specialty Tier, Select Care Drugs																								
H1350	026	0	1	01	01	H1350_026_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																			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																								
H1350	026	0	1	01	01	H1350_026_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	026	0	1	01	01	H1350_026_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	026	0	1	01	01	H1350_026_0	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.55	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	70.00				35.00		35.00
H1350	026	0	1	01	01	H1350_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				231.60	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	026	0	1	01	01	H1350_026_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	028	0	1	01	01	H1350_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	0.00	0.00	0.00																			0.00	0.00	0.00																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	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	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	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	028	0	1	01	01	H1350_028_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				39.89	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	70.00				35.00		35.00
H1350	028	0	1	01	01	H1350_028_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				161.93	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	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	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	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				57.05	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	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				252.54	30																				30																	30			30								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	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	030	0	1	01	01	H1350_030_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	030	0	1	01	01	H1350_030_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	030	0	1	01	01	H1350_030_0	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				50.56	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	70.00				35.00		35.00
H1350	030	0	1	01	01	H1350_030_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				303.07	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	030	0	1	01	01	H1350_030_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	031	1	1	01	01	H1350_031_1	6			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	031	1	1	01	01	H1350_031_1	6			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 Drug, Specialty Tier, Select Care Drugs																								
H1350	031	1	1	01	01	H1350_031_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																			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	031	1	1	01	01	H1350_031_1	6			Non-Preferred Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				41.40	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	70.00				35.00		35.00
H1350	031	1	1	01	01	H1350_031_1	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				168.86	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	031	1	1	01	01	H1350_031_1	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	031	2	1	01	01	H1350_031_2	6			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	031	2	1	01	01	H1350_031_2	6			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 Drug, Specialty Tier, Select Care Drugs																								
H1350	031	2	1	01	01	H1350_031_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																			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	031	2	1	01	01	H1350_031_2	6			Non-Preferred Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				41.40	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	70.00				35.00		35.00
H1350	031	2	1	01	01	H1350_031_2	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				168.86	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	031	2	1	01	01	H1350_031_2	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	031	3	1	01	01	H1350_031_3	6			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	031	3	1	01	01	H1350_031_3	6			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 Drug, Specialty Tier, Select Care Drugs																								
H1350	031	3	1	01	01	H1350_031_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																			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	031	3	1	01	01	H1350_031_3	6			Non-Preferred Drug	4	10	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				41.40	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	70.00				35.00		35.00
H1350	031	3	1	01	01	H1350_031_3	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				168.86	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1350	031	3	1	01	01	H1350_031_3	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	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								10.00	20.00	30.00					0.00	0.00	0.00					10.00	20.00	25.00																10.00				10.00			0.33	0.00	0.33			0.32	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					42.00	84.00	126.00					47.00	94.00	117.50																47.00				47.00			1.57	1.40	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											221.60	29						151.36	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	004	2	1	04	01	H1365_004_2	9			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																								
H1365	004	2	1	04	01	H1365_004_2	9			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					0.00	0.00	0.00					10.00	20.00	25.00																10.00				10.00			0.33	0.00	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1365	004	2	1	04	01	H1365_004_2	9			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											61.51	25	25	25				50.51	20	20	20				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		35.00
H1365	004	2	1	04	01	H1365_004_2	9			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											60.30	45	45	45				46.43	40	40	40				45	45	45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1365	004	2	1	04	01	H1365_004_2	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											228.67	30						133.56	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00						35.00		35.00
H1365	004	3	1	04	01	H1365_004_3	7			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																								
H1365	004	3	1	04	01	H1365_004_3	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	30.00					0.00	0.00	0.00					10.00	20.00	25.00																10.00				10.00			0.33	0.00	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1365	004	3	1	04	01	H1365_004_3	7			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											61.51	25	25	25				50.51	20	20	20				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		35.00
H1365	004	3	1	04	01	H1365_004_3	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											60.30	45	45	45				46.43	40	40	40				45	45	45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1365	004	3	1	04	01	H1365_004_3	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											228.67	30						133.56	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00						35.00		35.00
H1372	002	0	1	01	01	H1372_002_0	5			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	5			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	5			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	5			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
H1372	002	0	1	01	01	H1372_002_0	5			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31					29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H1372	003	0	1	01	01	H1372_003_0	6			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	6			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	6			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	6			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
H1372	003	0	1	01	01	H1372_003_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31					29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H1395	001	0	1	04	01	H1395_001_0	5		N	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					3.00	6.00	9.00											19.00	38.00	57.00				3.00	6.00	0.00				19.00				19.00			0.63	0.1		0.63	0.1	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1395	001	0	1	04	01	H1395_001_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1395	001	0	1	04	01	H1395_001_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											112.88	20	20	20				112.88	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
H1395	001	0	1	04	01	H1395_001_0	5		N	Non-Preferred Drug	3	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	200.00				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
H1395	001	0	1	04	01	H1395_001_0	5		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, Select Care Drugs																								
H1395	001	0	1	04	01	H1395_001_0	5		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	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	5			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																								
H1395	002	0	1	04	01	H1395_002_0	5			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																								
H1395	002	0	1	04	01	H1395_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.81	25	25	25				155.81	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
H1395	002	0	1	04	01	H1395_002_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											54.52	43	43	43				53.25	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
H1395	002	0	1	04	01	H1395_002_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, Select Care Drugs																								
H1395	002	0	1	04	01	H1395_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	0.00				0.00				0.00			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	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1395	003	0	1	04	01	H1395_003_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1395	003	0	1	04	01	H1395_003_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											123.02	20	20	20				123.02	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
H1395	003	0	1	04	01	H1395_003_0	5			Non-Preferred Drug	3	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	200.00				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
H1395	003	0	1	04	01	H1395_003_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																								
H1395	003	0	1	04	01	H1395_003_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																								
H1416	009	0	1	02	01	H1416_009_0	5			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	009	0	1	02	01	H1416_009_0	5			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																								
H1416	009	0	1	02	01	H1416_009_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											144.28	25	25	25				144.28	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
H1416	009	0	1	02	01	H1416_009_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											64.08	49	49	49				62.77	48	48	48										49	49	49				48	48	48			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
H1416	009	0	1	02	01	H1416_009_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, Select Care Drugs																								
H1416	009	0	1	02	01	H1416_009_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																								
H1416	026	0	1	02	01	H1416_026_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																								
H1416	026	0	1	02	01	H1416_026_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1416	026	0	1	02	01	H1416_026_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.94	25	25	25				151.94	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
H1416	026	0	1	02	01	H1416_026_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											54.34	40	40	40				52.98	39	39	39										40	40	40				39	39	39			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
H1416	026	0	1	02	01	H1416_026_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, Select Care Drugs																								
H1416	026	0	1	02	01	H1416_026_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																								
H1416	041	0	1	02	01	H1416_041_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	041	0	1	02	01	H1416_041_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	041	0	1	02	01	H1416_041_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											126.87	21	21	21				126.87	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
H1416	041	0	1	02	01	H1416_041_0	5			Non-Preferred Drug	3	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	200.00				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
H1416	041	0	1	02	01	H1416_041_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																								
H1416	041	0	1	02	01	H1416_041_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																								
H1416	042	0	1	02	01	H1416_042_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	042	0	1	02	01	H1416_042_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	042	0	1	02	01	H1416_042_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											127.88	21	21	21				127.88	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
H1416	042	0	1	02	01	H1416_042_0	5			Non-Preferred Drug	3	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	200.00				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
H1416	042	0	1	02	01	H1416_042_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																								
H1416	042	0	1	02	01	H1416_042_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																								
H1416	055	0	1	02	01	H1416_055_0	5			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	055	0	1	02	01	H1416_055_0	5			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																								
H1416	055	0	1	02	01	H1416_055_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.01	25	25	25				161.01	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
H1416	055	0	1	02	01	H1416_055_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											40.84	40	40	40				40.84	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
H1416	055	0	1	02	01	H1416_055_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, Select Care Drugs																								
H1416	055	0	1	02	01	H1416_055_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																								
H1416	064	0	1	02	01	H1416_064_0	5			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	064	0	1	02	01	H1416_064_0	5			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																								
H1416	064	0	1	02	01	H1416_064_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.71	25	25	25				164.71	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
H1416	064	0	1	02	01	H1416_064_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											51.66	50	50	50				49.59	48	48	48										50	50	50				48	48	48			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	02	01	H1416_064_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, Select Care Drugs																								
H1416	064	0	1	02	01	H1416_064_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																								
H1416	065	0	1	02	01	H1416_065_0	5			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	02	01	H1416_065_0	5			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																								
H1416	065	0	1	02	01	H1416_065_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.13	25	25	25				155.13	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
H1416	065	0	1	02	01	H1416_065_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											53.38	50	50	50				53.38	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	02	01	H1416_065_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, Select Care Drugs																								
H1416	065	0	1	02	01	H1416_065_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																								
H1416	068	0	1	02	01	H1416_068_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					15.00	30.00	45.00											19.00	38.00	57.00				15.00	30.00	0.00				19.00				19.00			0.63	0.5		0.63	0.5	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	068	0	1	02	01	H1416_068_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	068	0	1	02	01	H1416_068_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											134.05	22	22	22				134.05	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
H1416	068	0	1	02	01	H1416_068_0	5			Non-Preferred Drug	3	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	200.00				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
H1416	068	0	1	02	01	H1416_068_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																								
H1416	068	0	1	02	01	H1416_068_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			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	02	01	H1416_071_0	5			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	02	01	H1416_071_0	5			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																								
H1416	071	0	1	02	01	H1416_071_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.66	25	25	25				159.66	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
H1416	071	0	1	02	01	H1416_071_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											51.34	41	41	41				50.09	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
H1416	071	0	1	02	01	H1416_071_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, Select Care Drugs																								
H1416	071	0	1	02	01	H1416_071_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																								
H1416	072	0	1	02	01	H1416_072_0	5			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	02	01	H1416_072_0	5			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																								
H1416	072	0	1	02	01	H1416_072_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.95	25	25	25				155.95	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
H1416	072	0	1	02	01	H1416_072_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											70.71	49	49	49				70.71	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
H1416	072	0	1	02	01	H1416_072_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, Select Care Drugs																								
H1416	072	0	1	02	01	H1416_072_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																								
H1416	077	0	1	02	01	H1416_077_0	5			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	077	0	1	02	01	H1416_077_0	5			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																								
H1416	077	0	1	02	01	H1416_077_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											162.38	25	25	25				162.38	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
H1416	077	0	1	02	01	H1416_077_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											52.65	42	42	42				51.40	41	41	41										42	42	42				41	41	41			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
H1416	077	0	1	02	01	H1416_077_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, Select Care Drugs																								
H1416	077	0	1	02	01	H1416_077_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																								
H1416	079	0	1	02	01	H1416_079_0	5			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	079	0	1	02	01	H1416_079_0	5			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																								
H1416	079	0	1	02	01	H1416_079_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.87	25	25	25				154.87	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
H1416	079	0	1	02	01	H1416_079_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											55.34	50	50	50				55.34	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	02	01	H1416_079_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, Select Care Drugs																								
H1416	079	0	1	02	01	H1416_079_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																								
H1416	082	0	1	02	01	H1416_082_0	5			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	082	0	1	02	01	H1416_082_0	5			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																								
H1416	082	0	1	02	01	H1416_082_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											140.29	25	25	25				140.29	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
H1416	082	0	1	02	01	H1416_082_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											47.76	37	37	37				47.76	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
H1416	082	0	1	02	01	H1416_082_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, Select Care Drugs																								
H1416	082	0	1	02	01	H1416_082_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																								
H1416	083	0	1	02	01	H1416_083_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	083	0	1	02	01	H1416_083_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1416	083	0	1	02	01	H1416_083_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											142.41	23	23	23				136.22	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
H1416	083	0	1	02	01	H1416_083_0	5			Non-Preferred Drug	3	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	200.00				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
H1416	083	0	1	02	01	H1416_083_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																								
H1416	083	0	1	02	01	H1416_083_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																								
H1423	001	0	1	02	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	02	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	02	01	H1423_001_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											91.54	25	25	25				73.24	20	20	20				20	20	20															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	70.00				35.00		35.00
H1423	001	0	1	02	01	H1423_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.36	25	25	25				56.36	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		35.00
H1423	001	0	1	02	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	02	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	002	0	1	02	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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1423	002	0	1	02	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								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																								
H1423	002	0	1	02	01	H1423_002_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											127.21	25	25	25				101.76	20	20	20				20	20	20															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	70.00				35.00		35.00
H1423	002	0	1	02	01	H1423_002_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.77	25	25	25				58.77	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		35.00
H1423	002	0	1	02	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	02	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	004	0	1	02	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	02	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	02	01	H1423_004_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											94.69	25	25	25				75.75	20	20	20				20	20	20															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	70.00				35.00		35.00
H1423	004	0	1	02	01	H1423_004_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											61.27	25	25	25				61.27	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		35.00
H1423	004	0	1	02	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	02	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	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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1423	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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1423	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								30.00	60.00	90.00					25.00	50.00	75.00					25.00	50.00	50.00																30.00				30.00			1.00	0.83	0.83			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										25.00	50.00	75.00	25.00	50.00	75.00	25.00	50.00	50.00				25.00		25.00
H1423	005	0	1	01	01	H1423_005_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											62.27	25	25	25				62.27	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		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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	007	0	1	01	01	H1423_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1423	007	0	1	01	01	H1423_007_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	007	0	1	01	01	H1423_007_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				111.95	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	70.00				35.00		35.00
H1423	007	0	1	01	01	H1423_007_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				56.17	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
H1423	007	0	1	01	01	H1423_007_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	007	0	1	01	01	H1423_007_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			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			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			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				100.86	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	70.00				35.00		35.00
H1423	008	0	1	01	01	H1423_008_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				50.12	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
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	009	0	1	02	01	H1423_009_0	8			Preferred Generic	4	11	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	02	01	H1423_009_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H1423	009	0	1	02	01	H1423_009_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											67.84	20	20	20				67.87	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	70.00				35.00		35.00
H1423	009	0	1	02	01	H1423_009_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											62.62	35	35	35				62.62	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		35.00
H1423	009	0	1	02	01	H1423_009_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																								
H1463	003	0	1	01	01	H1463_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	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	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
H1463	003	0	1	01	01	H1463_003_0	7			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				119.45	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
H1463	003	0	1	01	01	H1463_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				66.69	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	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																								
H1463	015	0	1	02	01	H1463_015_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																								
H1463	015	0	1	02	01	H1463_015_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
H1463	015	0	1	02	01	H1463_015_0	6			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				126.37	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
H1463	015	0	1	02	01	H1463_015_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				68.23	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	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																								
H1463	019	0	1	02	01	H1463_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	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	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
H1463	019	0	1	02	01	H1463_019_0	7			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				119.90	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
H1463	019	0	1	02	01	H1463_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				68.18	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
H1463	019	0	1	02	01	H1463_019_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																								
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				122.20	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
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				78.06	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					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1463	044	0	1	02	01	H1463_044_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																								
H1463	044	0	1	02	01	H1463_044_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
H1463	044	0	1	02	01	H1463_044_0	6			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				126.25	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		35.00
H1463	044	0	1	02	01	H1463_044_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				66.85	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
H1463	044	0	1	02	01	H1463_044_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																								
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			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			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H1468	007	0	1	01	01	H1468_007_0	4			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																								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
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					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
H1468	013	0	1	01	01	H1468_013_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	013	0	1	01	01	H1468_013_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	013	0	1	01	01	H1468_013_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		95.00	35.00		35.00
H1468	013	0	1	01	01	H1468_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				78.00	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		35.00
H1468	013	0	1	01	01	H1468_013_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	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		95.00	35.00		35.00
H1468	014	0	1	01	01	H1468_014_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				84.00	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
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					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
H1468	017	0	1	01	01	H1468_017_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
H1468	017	0	1	01	01	H1468_017_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1468	017	0	1	01	01	H1468_017_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1468	017	0	1	01	01	H1468_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				85.00	50		50																								50		50				50		50			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		35.00
H1468	017	0	1	01	01	H1468_017_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
H1468	017	0	1	01	01	H1468_017_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
H1468	018	0	1	01	01	H1468_018_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	018	0	1	01	01	H1468_018_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	018	0	1	01	01	H1468_018_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		95.00	35.00		35.00
H1468	018	0	1	01	01	H1468_018_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				68.00	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
H1468	018	0	1	01	01	H1468_018_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	021	0	1	01	01	H1468_021_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	021	0	1	01	01	H1468_021_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	021	0	1	01	01	H1468_021_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		95.00	35.00		35.00
H1468	021	0	1	01	01	H1468_021_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H1468	021	0	1	01	01	H1468_021_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
H1468	022	0	1	01	01	H1468_022_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1468	022	0	1	01	01	H1468_022_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1468	022	0	1	01	01	H1468_022_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1468	022	0	1	01	01	H1468_022_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1468	022	0	1	01	01	H1468_022_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1468	022	0	1	01	01	H1468_022_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
H1526	001	0	1	02	01	H1526_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	0.00	0.00	0.00																			0.00	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	10			Generic	4	01	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 Brand, Specialty Tier, Select Diabetic Drugs																								
H1526	001	0	1	02	01	H1526_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	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																								
H1526	001	0	1	02	01	H1526_001_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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1526	001	0	1	02	01	H1526_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	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	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
H1526	003	0	1	02	01	H1526_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																								
H1526	003	0	1	02	01	H1526_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																								
H1526	003	0	1	02	01	H1526_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	117.00																			40.00	40.00	40.00																47.00				47.00		1.57			1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H1526	003	0	1	02	01	H1526_003_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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1526	003	0	1	02	01	H1526_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	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	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
H1526	005	0	1	02	01	H1526_005_0	8			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																								
H1526	005	0	1	02	01	H1526_005_0	8			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										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	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	117.00																			40.00	40.00	40.00																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	35.00	35.00				35.00		35.00
H1526	005	0	1	02	01	H1526_005_0	8			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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1526	005	0	1	02	01	H1526_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1000.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H1526	008	0	1	02	01	H1526_008_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 Brand, Specialty Tier, Select Diabetic Drugs																								
H1526	008	0	1	02	01	H1526_008_0	9			Generic	4	01	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 Brand, Specialty Tier, Select Diabetic Drugs																								
H1526	008	0	1	02	01	H1526_008_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																			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																								
H1526	008	0	1	02	01	H1526_008_0	9			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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1526	008	0	1	02	01	H1526_008_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H1526	008	0	1	02	01	H1526_008_0	9			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	009	0	1	02	01	H1526_009_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																								
H1526	009	0	1	02	01	H1526_009_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																								
H1526	009	0	1	02	01	H1526_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	117.00																			40.00	40.00	40.00																47.00				47.00		1.57			1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H1526	009	0	1	02	01	H1526_009_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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1526	009	0	1	02	01	H1526_009_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H1526	009	0	1	02	01	H1526_009_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
H1607	012	0	1	04	01	H1607_012_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																								
H1607	012	0	1	04	01	H1607_012_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																								
H1607	012	0	1	04	01	H1607_012_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											49.07	20	20	20				49.07	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	70.00				35.00		35.00
H1607	012	0	1	04	01	H1607_012_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											58.98	35	35	35				58.98	35	35	35				35	35	35															35			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
H1607	012	0	1	04	01	H1607_012_0	6			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	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																								
H1607	015	0	1	04	01	H1607_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																								
H1607	015	0	1	04	01	H1607_015_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H1607	015	0	1	04	01	H1607_015_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.32	20	20	20				56.32	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	70.00				35.00		35.00
H1607	015	0	1	04	01	H1607_015_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											60.81	35	35	35				60.81	35	35	35				35	35	35															35			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
H1607	015	0	1	04	01	H1607_015_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																								
H1607	015	0	1	04	01	H1607_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																								
H1608	001	0	1	04	01	H1608_001_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	001	0	1	04	01	H1608_001_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	001	0	1	04	01	H1608_001_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.15	24	24	24				109.56	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
H1608	001	0	1	04	01	H1608_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.61	25	25	25				28.99	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
H1608	001	0	1	04	01	H1608_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											769.93	25						775.37	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
H1608	012	0	1	04	01	H1608_012_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	012	0	1	04	01	H1608_012_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	012	0	1	04	01	H1608_012_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.20	24	24	24				97.34	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
H1608	012	0	1	04	01	H1608_012_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.90	25	25	25				31.54	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
H1608	012	0	1	04	01	H1608_012_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											672.75	25						714.28	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
H1608	013	0	1	04	01	H1608_013_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	013	0	1	04	01	H1608_013_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	013	0	1	04	01	H1608_013_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.22	24	24	24				102.15	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
H1608	013	0	1	04	01	H1608_013_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.02	25	25	25				35.38	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
H1608	013	0	1	04	01	H1608_013_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											889.30	25						741.09	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
H1608	016	0	1	04	01	H1608_016_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	016	0	1	04	01	H1608_016_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	016	0	1	04	01	H1608_016_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.59	24	24	24				107.02	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
H1608	016	0	1	04	01	H1608_016_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.16	25	25	25				38.85	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
H1608	016	0	1	04	01	H1608_016_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											751.45	25						713.29	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
H1608	017	0	1	04	01	H1608_017_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	017	0	1	04	01	H1608_017_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	017	0	1	04	01	H1608_017_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.54	24	24	24				112.16	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
H1608	017	0	1	04	01	H1608_017_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.84	25	25	25				36.55	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
H1608	017	0	1	04	01	H1608_017_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											760.75	25						941.72	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
H1608	018	0	1	04	01	H1608_018_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	018	0	1	04	01	H1608_018_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1608	018	0	1	04	01	H1608_018_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.78	25	25	25				108.32	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
H1608	018	0	1	04	01	H1608_018_0	3			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	26	26	26				33.49	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											929.93	30						836.98	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
H1608	021	0	1	04	01	H1608_021_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	021	0	1	04	01	H1608_021_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	021	0	1	04	01	H1608_021_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.37	21	21	21				63.95	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	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.25	50	50	50				34.22	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	105.00	35.00		35.00
H1608	021	0	1	04	01	H1608_021_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1074.25	33						1129.15	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	024	0	1	04	01	H1608_024_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	024	0	1	04	01	H1608_024_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	024	0	1	04	01	H1608_024_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.09	24	24	24				98.37	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
H1608	024	0	1	04	01	H1608_024_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.27	25	25	25				33.25	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
H1608	024	0	1	04	01	H1608_024_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.78	25						816.34	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
H1608	027	0	1	04	01	H1608_027_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	027	0	1	04	01	H1608_027_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	027	0	1	04	01	H1608_027_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.92	24	24	24				115.10	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
H1608	027	0	1	04	01	H1608_027_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											34.81	25	25	25				30.29	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
H1608	027	0	1	04	01	H1608_027_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											698.55	25						921.01	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
H1608	028	0	1	04	01	H1608_028_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	028	0	1	04	01	H1608_028_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	028	0	1	04	01	H1608_028_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.85	21	21	21				71.94	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	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.23	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
H1608	028	0	1	04	01	H1608_028_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1330.86	33						1107.94	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
H1608	029	0	1	04	01	H1608_029_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	029	0	1	04	01	H1608_029_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	029	0	1	04	01	H1608_029_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.04	24	24	24				116.71	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
H1608	029	0	1	04	01	H1608_029_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.16	25	25	25				30.26	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
H1608	029	0	1	04	01	H1608_029_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											894.31	25						727.70	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
H1608	031	0	1	04	01	H1608_031_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	031	0	1	04	01	H1608_031_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	031	0	1	04	01	H1608_031_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.18	24	24	24				111.29	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
H1608	031	0	1	04	01	H1608_031_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.00	25	25	25				35.75	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
H1608	031	0	1	04	01	H1608_031_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											844.97	25						925.09	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
H1608	037	0	1	04	01	H1608_037_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	037	0	1	04	01	H1608_037_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	037	0	1	04	01	H1608_037_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.60	24	24	24				105.69	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
H1608	037	0	1	04	01	H1608_037_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.85	25	25	25				30.54	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
H1608	037	0	1	04	01	H1608_037_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											692.16	25						799.77	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
H1608	038	0	1	04	01	H1608_038_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	038	0	1	04	01	H1608_038_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	038	0	1	04	01	H1608_038_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.35	24	24	24				100.98	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
H1608	038	0	1	04	01	H1608_038_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.46	25	25	25				32.73	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
H1608	038	0	1	04	01	H1608_038_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											708.67	25						675.31	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
H1608	040	0	1	04	01	H1608_040_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	040	0	1	04	01	H1608_040_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	040	0	1	04	01	H1608_040_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.95	24	24	24				112.19	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
H1608	040	0	1	04	01	H1608_040_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.13	25	25	25				35.11	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
H1608	040	0	1	04	01	H1608_040_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											721.95	25						644.11	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
H1608	050	0	1	04	01	H1608_050_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	050	0	1	04	01	H1608_050_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	050	0	1	04	01	H1608_050_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.89	24	24	24				107.57	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
H1608	050	0	1	04	01	H1608_050_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.00	25	25	25				40.66	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
H1608	050	0	1	04	01	H1608_050_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											961.81	25						919.02	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
H1608	051	0	1	04	01	H1608_051_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	051	0	1	04	01	H1608_051_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	051	0	1	04	01	H1608_051_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.50	24	24	24				99.66	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
H1608	051	0	1	04	01	H1608_051_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.68	25	25	25				38.32	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
H1608	051	0	1	04	01	H1608_051_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											681.15	25						762.15	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
H1608	052	0	1	04	01	H1608_052_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	052	0	1	04	01	H1608_052_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	052	0	1	04	01	H1608_052_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.31	24	24	24				101.36	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
H1608	052	0	1	04	01	H1608_052_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.54	25	25	25				36.21	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
H1608	052	0	1	04	01	H1608_052_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											756.48	25						741.48	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
H1608	054	0	1	04	01	H1608_054_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	054	0	1	04	01	H1608_054_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	054	0	1	04	01	H1608_054_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.91	24	24	24				98.41	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
H1608	054	0	1	04	01	H1608_054_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.19	25	25	25				33.28	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
H1608	054	0	1	04	01	H1608_054_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											635.78	25						672.89	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
H1608	064	0	1	04	01	H1608_064_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	064	0	1	04	01	H1608_064_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1608	064	0	1	04	01	H1608_064_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.87	25	25	25				93.89	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
H1608	064	0	1	04	01	H1608_064_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.23	26	26	26				33.45	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											834.57	30						811.99	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
H1608	067	0	1	04	01	H1608_067_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	067	0	1	04	01	H1608_067_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	067	0	1	04	01	H1608_067_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.61	24	24	24				101.61	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
H1608	067	0	1	04	01	H1608_067_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.75	25	25	25				32.80	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
H1608	067	0	1	04	01	H1608_067_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											768.11	25						729.35	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
H1608	070	0	1	04	01	H1608_070_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	070	0	1	04	01	H1608_070_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	070	0	1	04	01	H1608_070_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.37	24	24	24				102.17	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
H1608	070	0	1	04	01	H1608_070_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.67	25	25	25				33.11	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
H1608	070	0	1	04	01	H1608_070_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.40	25						761.14	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
H1608	072	0	1	04	01	H1608_072_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	072	0	1	04	01	H1608_072_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	072	0	1	04	01	H1608_072_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.37	24	24	24				102.17	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
H1608	072	0	1	04	01	H1608_072_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.67	25	25	25				33.10	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
H1608	072	0	1	04	01	H1608_072_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.40	25						760.62	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
H1608	073	0	1	04	01	H1608_073_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	073	0	1	04	01	H1608_073_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	073	0	1	04	01	H1608_073_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.13	24	24	24				93.76	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
H1608	073	0	1	04	01	H1608_073_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.43	25	25	25				31.47	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
H1608	073	0	1	04	01	H1608_073_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											678.92	25						682.25	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
H1608	075	0	1	04	01	H1608_075_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	075	0	1	04	01	H1608_075_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1608	075	0	1	04	01	H1608_075_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					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	075	0	1	04	01	H1608_075_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											700.62	25						675.88	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
H1608	078	0	1	04	01	H1608_078_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	078	0	1	04	01	H1608_078_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	078	0	1	04	01	H1608_078_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.13	24	24	24				93.75	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
H1608	078	0	1	04	01	H1608_078_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.43	25	25	25				31.48	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
H1608	078	0	1	04	01	H1608_078_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											678.71	25						683.23	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
H1608	079	0	1	04	01	H1608_079_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	079	0	1	04	01	H1608_079_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	079	0	1	04	01	H1608_079_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.25	24	24	24				95.36	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
H1608	079	0	1	04	01	H1608_079_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.07	25	25	25				31.57	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
H1608	079	0	1	04	01	H1608_079_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											702.99	25						673.55	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
H1608	080	0	1	04	01	H1608_080_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	080	0	1	04	01	H1608_080_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	080	0	1	04	01	H1608_080_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											27.14	22	22	22				33.65	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	080	0	1	04	01	H1608_080_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.45	25	25	25				44.03	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
H1608	080	0	1	04	01	H1608_080_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											315.34	25						293.26	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
H1608	081	0	1	04	01	H1608_081_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	081	0	1	04	01	H1608_081_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	081	0	1	04	01	H1608_081_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											29.38	22	22	22				36.29	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	081	0	1	04	01	H1608_081_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.58	25	25	25				41.66	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
H1608	081	0	1	04	01	H1608_081_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											318.31	25						283.76	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
H1608	082	0	1	04	01	H1608_082_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	082	0	1	04	01	H1608_082_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	082	0	1	04	01	H1608_082_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											30.85	22	22	22				37.30	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	082	0	1	04	01	H1608_082_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.65	25	25	25				40.68	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
H1608	082	0	1	04	01	H1608_082_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											319.72	25						278.91	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
H1608	085	0	1	04	01	H1608_085_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	085	0	1	04	01	H1608_085_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	085	0	1	04	01	H1608_085_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.08	22	22	22				44.10	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	085	0	1	04	01	H1608_085_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.12	25	25	25				46.21	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
H1608	085	0	1	04	01	H1608_085_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											378.42	25						334.17	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
H1608	105	0	1	04	01	H1608_105_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	105	0	1	04	01	H1608_105_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	105	0	1	04	01	H1608_105_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.46	24	24	24				94.85	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
H1608	105	0	1	04	01	H1608_105_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.68	25	25	25				32.21	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
H1608	105	0	1	04	01	H1608_105_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											719.80	25						673.70	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
H1608	109	0	1	04	01	H1608_109_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	109	0	1	04	01	H1608_109_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1608	109	0	1	04	01	H1608_109_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.71	24	24	24				111.31	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
H1608	109	0	1	04	01	H1608_109_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.51	25	25	25				37.65	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
H1608	109	0	1	04	01	H1608_109_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											855.78	25						802.28	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
H1609	001	0	1	02	01	H1609_001_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	001	0	1	02	01	H1609_001_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	001	0	1	02	01	H1609_001_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.16	24	24	24				112.61	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
H1609	001	0	1	02	01	H1609_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.66	25	25	25				29.01	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	001	0	1	02	01	H1609_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											902.07	25						744.08	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	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	018	0	1	01	01	H1609_018_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	018	0	1	01	01	H1609_018_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.86	25	25	25				80.76	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	018	0	1	01	01	H1609_018_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											56.60	35	35	35				35.01	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
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											1202.76	33						1140.92	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
H1609	020	0	1	01	01	H1609_020_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	020	0	1	01	01	H1609_020_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	020	0	1	01	01	H1609_020_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.28	25	25	25				84.59	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	020	0	1	01	01	H1609_020_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											48.12	35	35	35				33.08	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
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											1116.57	33						1040.07	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	021	0	1	01	01	H1609_021_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	021	0	1	01	01	H1609_021_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	021	0	1	01	01	H1609_021_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.34	25	25	25				75.94	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	021	0	1	01	01	H1609_021_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											40.52	35	35	35				26.97	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
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											1064.81	33						819.78	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
H1609	022	0	1	01	01	H1609_022_0	7			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	022	0	1	01	01	H1609_022_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	022	0	1	01	01	H1609_022_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.05	25	25	25				75.14	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	022	0	1	01	01	H1609_022_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											38.64	35	35	35				28.56	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
H1609	022	0	1	01	01	H1609_022_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											872.09	33						1046.48	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
H1609	025	0	1	01	01	H1609_025_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	025	0	1	01	01	H1609_025_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	025	0	1	01	01	H1609_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											58.11	25	25	25				79.21	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	025	0	1	01	01	H1609_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											38.35	35	35	35				29.87	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
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											902.66	33						948.54	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
H1609	026	0	1	01	01	H1609_026_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	026	0	1	01	01	H1609_026_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	026	0	1	01	01	H1609_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											63.40	25	25	25				83.10	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	026	0	1	01	01	H1609_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											37.06	35	35	35				32.11	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
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											946.58	33						1005.16	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
H1609	027	0	1	01	01	H1609_027_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	027	0	1	01	01	H1609_027_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	027	0	1	01	01	H1609_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											59.96	25	25	25				81.89	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	027	0	1	01	01	H1609_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											35.12	35	35	35				27.98	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
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											928.92	33						801.22	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
H1609	028	0	1	02	01	H1609_028_0	5			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	028	0	1	02	01	H1609_028_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	028	0	1	02	01	H1609_028_0	5			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.77	24	24	24				96.62	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
H1609	028	0	1	02	01	H1609_028_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											40.73	25	25	25				34.97	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	028	0	1	02	01	H1609_028_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											716.06	25						737.08	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	035	0	1	01	01	H1609_035_0	7			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	035	0	1	01	01	H1609_035_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	035	0	1	01	01	H1609_035_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.39	25	25	25				78.92	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	035	0	1	01	01	H1609_035_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											40.58	35	35	35				29.68	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
H1609	035	0	1	01	01	H1609_035_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											884.43	33						897.46	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
H1609	038	0	1	01	01	H1609_038_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	038	0	1	01	01	H1609_038_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	038	0	1	01	01	H1609_038_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.22	25	25	25				77.45	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	038	0	1	01	01	H1609_038_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											38.49	35	35	35				28.14	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
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											882.21	33						899.08	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	041	0	1	01	01	H1609_041_0	7			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	041	0	1	01	01	H1609_041_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	041	0	1	01	01	H1609_041_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.00	25	25	25				80.95	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	041	0	1	01	01	H1609_041_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											36.89	35	35	35				28.25	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
H1609	041	0	1	01	01	H1609_041_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1106.09	33						873.01	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
H1609	042	0	1	01	01	H1609_042_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	042	0	1	01	01	H1609_042_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	042	0	1	01	01	H1609_042_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.86	25	25	25				79.26	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	042	0	1	01	01	H1609_042_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											41.64	35	35	35				27.68	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
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											1015.18	33						857.71	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
H1609	059	0	1	01	01	H1609_059_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	059	0	1	01	01	H1609_059_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	059	0	1	01	01	H1609_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											57.25	25	25	25				78.02	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	059	0	1	01	01	H1609_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											38.26	35	35	35				28.08	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
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											986.19	33						822.55	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
H1609	063	0	1	01	01	H1609_063_0	7			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	063	0	1	01	01	H1609_063_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	063	0	1	01	01	H1609_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											58.53	25	25	25				73.29	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	063	0	1	01	01	H1609_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											34.43	35	35	35				26.23	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
H1609	063	0	1	01	01	H1609_063_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											927.20	33						879.65	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	066	0	1	01	01	H1609_066_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	066	0	1	01	01	H1609_066_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	066	0	1	01	01	H1609_066_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.26	25	25	25				80.89	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	066	0	1	01	01	H1609_066_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											60.11	35	35	35				46.75	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
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											998.00	33						1237.96	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
H1609	067	0	1	01	01	H1609_067_0	6			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	067	0	1	01	01	H1609_067_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	067	0	1	01	01	H1609_067_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.52	25	25	25				76.42	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	067	0	1	01	01	H1609_067_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											43.75	35	35	35				30.39	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
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											919.36	33						1093.59	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	068	0	1	02	01	H1609_068_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	068	0	1	02	01	H1609_068_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	068	0	1	02	01	H1609_068_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.98	24	24	24				90.16	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
H1609	068	0	1	02	01	H1609_068_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											38.59	25	25	25				36.59	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	068	0	1	02	01	H1609_068_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											654.78	25						646.88	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	069	0	1	02	01	H1609_069_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	069	0	1	02	01	H1609_069_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1609	069	0	1	02	01	H1609_069_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.63	24	24	24				98.12	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
H1609	069	0	1	02	01	H1609_069_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.57	25	25	25				31.55	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
H1609	069	0	1	02	01	H1609_069_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											744.98	25						702.63	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
H1619	001	0	1	04	01	H1619_001_0	22			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																								
H1619	001	0	1	04	01	H1619_001_0	22			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	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																								
H1619	001	0	1	04	01	H1619_001_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H1619	001	0	1	04	01	H1619_001_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				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
H1619	001	0	1	04	01	H1619_001_0	22			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										35.00						35.00						35.00		35.00
H1619	002	0	1	04	01	H1619_002_0	22			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																								
H1619	002	0	1	04	01	H1619_002_0	22			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	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																								
H1619	002	0	1	04	01	H1619_002_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H1619	002	0	1	04	01	H1619_002_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				100.00	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	70.00				35.00		35.00
H1619	002	0	1	04	01	H1619_002_0	22			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										35.00						35.00						35.00		35.00
H1619	003	0	1	04	01	H1619_003_0	22			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																								
H1619	003	0	1	04	01	H1619_003_0	22			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	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																								
H1619	003	0	1	04	01	H1619_003_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H1619	003	0	1	04	01	H1619_003_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				100.00	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	70.00				35.00		35.00
H1619	003	0	1	04	01	H1619_003_0	22			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										35.00						35.00						35.00		35.00
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				203.00	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
H1664	001	0	1	02	01	H1664_001_0	5			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																								
H1664	001	0	1	02	01	H1664_001_0	5			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																								
H1664	001	0	1	02	01	H1664_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.90	25	25	25				155.90	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
H1664	001	0	1	02	01	H1664_001_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											54.94	36	36	36				53.41	35	35	35										36	36	36				35	35	35			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
H1664	001	0	1	02	01	H1664_001_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, Select Care Drugs																								
H1664	001	0	1	02	01	H1664_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1664	005	0	1	02	01	H1664_005_0	5		N	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					11.00	22.00	33.00											19.00	38.00	57.00				11.00	22.00	0.00				19.00				19.00			0.63	0.37		0.63	0.37	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1664	005	0	1	02	01	H1664_005_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1664	005	0	1	02	01	H1664_005_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											106.51	19	19	19				106.51	19	19	19										19	19	19				19	19	19			19			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	70.00	105.00	35.00		35.00
H1664	005	0	1	02	01	H1664_005_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											47.18	48	48	48				47.18	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
H1664	005	0	1	02	01	H1664_005_0	5		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, Select Care Drugs																								
H1664	005	0	1	02	01	H1664_005_0	5		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	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	02	01	H1664_006_0	5			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																								
H1664	006	0	1	02	01	H1664_006_0	5			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																								
H1664	006	0	1	02	01	H1664_006_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.42	25	25	25				159.42	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
H1664	006	0	1	02	01	H1664_006_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											58.20	37	37	37				56.63	36	36	36										37	37	37				36	36	36			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
H1664	006	0	1	02	01	H1664_006_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, Select Care Drugs																								
H1664	006	0	1	02	01	H1664_006_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																								
H1664	012	0	1	02	01	H1664_012_0	5		N	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					12.00	24.00	36.00											19.00	38.00	57.00				12.00	24.00	0.00				19.00				19.00			0.63	0.4		0.63	0.4	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1664	012	0	1	02	01	H1664_012_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1664	012	0	1	02	01	H1664_012_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											119.00	20	20	20				119.00	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
H1664	012	0	1	02	01	H1664_012_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											31.20	34	34	34				31.20	34	34	34										34	34	34				34	34	34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	012	0	1	02	01	H1664_012_0	5		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, Select Care Drugs																								
H1664	012	0	1	02	01	H1664_012_0	5		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	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	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	003	0	1	04	01	H1666_003_0	6			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	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	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	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	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											96.36	50	50	50				99.52	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
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											637.68	30						464.91	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	006	0	1	04	01	H1666_006_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	006	0	1	04	01	H1666_006_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	006	0	1	04	01	H1666_006_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.89	50	50	50				98.97	44	44	44										50	50	50				44	44	44			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
H1666	006	0	1	04	01	H1666_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											490.56	25						464.08	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	008	0	1	04	01	H1666_008_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	008	0	1	04	01	H1666_008_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	008	0	1	04	01	H1666_008_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											68.80	50	50	50				77.34	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
H1666	008	0	1	04	01	H1666_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											658.92	33						503.64	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	012	0	1	04	01	H1666_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	012	0	1	04	01	H1666_012_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	012	0	1	04	01	H1666_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	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	012	0	1	04	01	H1666_012_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											99.92	34	34	34				96.23	33	33	33										34	34	34				33	33	33			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
H1666	012	0	1	04	01	H1666_012_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											753.78	33						581.80	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	014	0	1	04	01	H1666_014_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	014	0	1	04	01	H1666_014_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	014	0	1	04	01	H1666_014_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	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	014	0	1	04	01	H1666_014_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											104.32	25	25	25				85.82	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
H1666	014	0	1	04	01	H1666_014_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											512.21	25						539.81	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	015	0	1	04	01	H1666_015_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	015	0	1	04	01	H1666_015_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	015	0	1	04	01	H1666_015_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	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	015	0	1	04	01	H1666_015_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											106.83	25	25	25				95.19	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
H1666	015	0	1	04	01	H1666_015_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											485.43	25						475.96	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	016	0	1	04	01	H1666_016_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	016	0	1	04	01	H1666_016_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	016	0	1	04	01	H1666_016_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	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	016	0	1	04	01	H1666_016_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											97.40	26	26	26				93.90	26	26	26										26	26	26				26	26	26			26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											565.03	25						526.32	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	019	0	1	04	01	H1666_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	019	0	1	04	01	H1666_019_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	019	0	1	04	01	H1666_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	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	019	0	1	04	01	H1666_019_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											99.71	48	48	48				91.24	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
H1666	019	0	1	04	01	H1666_019_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											613.45	30						536.79	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	020	0	1	04	01	H1666_020_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	020	0	1	04	01	H1666_020_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	020	0	1	04	01	H1666_020_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	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	020	0	1	04	01	H1666_020_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											79.58	50	50	50				69.48	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
H1666	020	0	1	04	01	H1666_020_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											651.91	33						586.17	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	021	0	1	04	01	H1666_021_0	12			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	021	0	1	04	01	H1666_021_0	12			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	021	0	1	04	01	H1666_021_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	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	021	0	1	04	01	H1666_021_0	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.66	49	49	49				91.15	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
H1666	021	0	1	04	01	H1666_021_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											488.90	25						422.34	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	022	0	1	04	01	H1666_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	022	0	1	04	01	H1666_022_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	022	0	1	04	01	H1666_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					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	022	0	1	04	01	H1666_022_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											68.72	50	50	50				75.04	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
H1666	022	0	1	04	01	H1666_022_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											581.24	33						553.33	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	023	0	1	04	01	H1666_023_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				0.00	0.00	0.00				18.00				18.00			0.60	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	023	0	1	04	01	H1666_023_0	6			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	023	0	1	04	01	H1666_023_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	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	023	0	1	04	01	H1666_023_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											91.92	50	50	50				99.52	47	47	47										50	50	50				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	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	023	0	1	04	01	H1666_023_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											575.01	30						507.92	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1666	024	0	1	04	01	H1666_024_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H1666	024	0	1	04	01	H1666_024_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H1666	024	0	1	04	01	H1666_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								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	024	0	1	04	01	H1666_024_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											68.72	50	50	50				75.04	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
H1666	024	0	1	04	01	H1666_024_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											581.26	33						553.37	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1692	002	0	1	01	01	H1692_002_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1692	002	0	1	01	01	H1692_002_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1692	002	0	1	01	01	H1692_002_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.98	22	22	22				102.04	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	01	01	H1692_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.06	25	25	25				32.43	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
H1692	002	0	1	01	01	H1692_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											927.32	27						806.44	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
H1692	003	0	1	01	01	H1692_003_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1692	003	0	1	01	01	H1692_003_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1692	003	0	1	01	01	H1692_003_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.36	24	24	24				110.35	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
H1692	003	0	1	01	01	H1692_003_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.47	25	25	25				36.86	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
H1692	003	0	1	01	01	H1692_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											783.60	25						811.99	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
H1692	007	0	1	01	01	H1692_007_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1692	007	0	1	01	01	H1692_007_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H1692	007	0	1	01	01	H1692_007_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.61	24	24	24				113.40	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
H1692	007	0	1	01	01	H1692_007_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.74	25	25	25				38.04	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
H1692	007	0	1	01	01	H1692_007_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											799.42	25						878.50	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
H1722	002	0	1	01	01	H1722_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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	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	15.00																			15.00	30.00	15.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	30.00	15.00				15.00	30.00	15.00				15.00		15.00
H1722	002	0	1	01	01	H1722_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	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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				55.17	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
H1722	002	0	1	01	01	H1722_002_0	7			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
H1723	001	0	1	48	05	H1723_001_0	1			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	1			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	1			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	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																								
H1737	001	0	1	01	01	H1737_001_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
H1737	001	0	1	01	01	H1737_001_0	6			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				125.57	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
H1737	001	0	1	01	01	H1737_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				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
H1737	001	0	1	01	01	H1737_001_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																								
H1748	003	0	1	01	01	H1748_003_0	6			Preferred Generic	4	01	1	2	1	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, Select Care Drugs																								
H1748	003	0	1	01	01	H1748_003_0	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	2			90				30		31	15.00		45.00																					45.00																15.00				15.00		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
H1748	003	0	1	01	01	H1748_003_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	6			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										0.00		0.00						0.00				0.00		0.00
H1748	003	0	1	01	01	H1748_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1087.96	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	6			Select Care Drugs	4	11	1	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, Select Care Drugs																								
H1748	004	0	1	01	01	H1748_004_0	8			Preferred Generic	4	01	1	2	1	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, Select Care Drugs																								
H1748	004	0	1	01	01	H1748_004_0	8			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										15.00		45.00						0.00				15.00		15.00
H1748	004	0	1	01	01	H1748_004_0	8			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	8			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		70.00						70.00				35.00		35.00
H1748	004	0	1	01	01	H1748_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1095.77	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	8			Select Care Drugs	4	11	1	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, Select Care Drugs																								
H1748	005	0	1	01	01	H1748_005_0	8		N	Preferred Generic	4	01	1	1	1	1	110		01	110		1	30		90				1	2	30		90				30		31					25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1748	005	0	1	01	01	H1748_005_0	8		N	Generic	4	01	3	1	2	1	110		01	110		1	30		90				1	2	30		90				30		31					25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										10.00		30.00				0.00		0.00				10.00		10.00
H1748	005	0	1	01	01	H1748_005_0	8		N	Preferred Brand	4	10	1	1	3	1	110		01	110		1	30		90				1	2	30		90				30		31					25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		70.00				35.00		70.00				35.00		35.00
H1748	005	0	1	01	01	H1748_005_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				1	2	30		90				30		31					25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		70.00				35.00		70.00				35.00		35.00
H1748	005	0	1	01	01	H1748_005_0	8		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																								
H1748	010	0	1	01	01	H1748_010_0	7			Preferred Generic	4	01	1	2	1	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																								
H1748	010	0	1	01	01	H1748_010_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										10.00		30.00						0.00				10.00		10.00
H1748	010	0	1	01	01	H1748_010_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	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										35.00		70.00						70.00				35.00		35.00
H1748	010	0	1	01	01	H1748_010_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1136.36	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1748	011	0	1	01	01	H1748_011_0	6			Preferred Generic	4	01	1	2	1	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, Select Care Drugs																								
H1748	011	0	1	01	01	H1748_011_0	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										15.00		45.00						0.00				15.00		15.00
H1748	011	0	1	01	01	H1748_011_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	011	0	1	01	01	H1748_011_0	6			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		70.00						70.00				35.00		35.00
H1748	011	0	1	01	01	H1748_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1095.77	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1748	011	0	1	01	01	H1748_011_0	6			Select Care Drugs	4	11	1	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, Select Care Drugs																								
H1748	012	0	1	01	01	H1748_012_0	8			Preferred Generic	4	01	1	2	1	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, Select Care Drugs																								
H1748	012	0	1	01	01	H1748_012_0	8			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										0.00		0.00						0.00				0.00		0.00
H1748	012	0	1	01	01	H1748_012_0	8			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	012	0	1	01	01	H1748_012_0	8			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										0.00		0.00						0.00				0.00		0.00
H1748	012	0	1	01	01	H1748_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1095.77	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1748	012	0	1	01	01	H1748_012_0	8			Select Care Drugs	4	11	1	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, Select Care Drugs																								
H1748	013	0	1	01	01	H1748_013_0	6			Preferred Generic	4	01	1	2	1	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, Select Care Drugs																								
H1748	013	0	1	01	01	H1748_013_0	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										15.00		45.00						0.00				15.00		15.00
H1748	013	0	1	01	01	H1748_013_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	013	0	1	01	01	H1748_013_0	6			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		70.00						70.00				35.00		35.00
H1748	013	0	1	01	01	H1748_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1095.77	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1748	013	0	1	01	01	H1748_013_0	6			Select Care Drugs	4	11	1	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, Select Care Drugs																								
H1748	014	0	1	01	01	H1748_014_0	7			Preferred Generic	4	01	1	2	1	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																								
H1748	014	0	1	01	01	H1748_014_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										10.00		30.00						0.00				10.00		10.00
H1748	014	0	1	01	01	H1748_014_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	014	0	1	01	01	H1748_014_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										35.00		70.00						70.00				35.00		35.00
H1748	014	0	1	01	01	H1748_014_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1136.36	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1748	015	0	1	01	01	H1748_015_0	8			Preferred Generic	4	01	1	2	1	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																								
H1748	015	0	1	01	01	H1748_015_0	8			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										10.00		30.00						0.00				10.00		10.00
H1748	015	0	1	01	01	H1748_015_0	8			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	015	0	1	01	01	H1748_015_0	8			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										35.00		70.00						70.00				35.00		35.00
H1748	015	0	1	01	01	H1748_015_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1136.36	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1748	016	0	1	01	01	H1748_016_0	7			Preferred Generic	4	01	1	2	1	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																								
H1748	016	0	1	01	01	H1748_016_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										10.00		30.00						0.00				10.00		10.00
H1748	016	0	1	01	01	H1748_016_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	016	0	1	01	01	H1748_016_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										35.00		70.00						70.00				35.00		35.00
H1748	016	0	1	01	01	H1748_016_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1136.36	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1748	017	0	1	01	01	H1748_017_0	6			Preferred Generic	4	01	1	2	1	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																								
H1748	017	0	1	01	01	H1748_017_0	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										10.00		30.00						0.00				10.00		10.00
H1748	017	0	1	01	01	H1748_017_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	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	017	0	1	01	01	H1748_017_0	6			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										35.00		70.00						70.00				35.00		35.00
H1748	017	0	1	01	01	H1748_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1136.36	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1774	001	0	1	04	01	H1774_001_0	5			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	5			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																								
H1774	001	0	1	04	01	H1774_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.94	25	25	25				161.94	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
H1774	001	0	1	04	01	H1774_001_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											61.53	44	44	44				60.13	43	43	43										44	44	44				43	43	43			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
H1774	001	0	1	04	01	H1774_001_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, Select Care Drugs																								
H1774	001	0	1	04	01	H1774_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	0.00				0.00				0.00			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	5			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	5			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										10.00	20.00	30.00										10.00		10.00
H1787	002	0	1	01	01	H1787_002_0	5			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	5			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	5			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31				488.65	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	5			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																								
H1822	001	0	1	01	01	H1822_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								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																								
H1822	001	0	1	01	01	H1822_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	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																								
H1822	001	0	1	01	01	H1822_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H1822	001	0	1	01	01	H1822_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											64.11	50	50	50				64.11	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
H1822	001	0	1	01	01	H1822_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																								
H1822	002	0	1	01	01	H1822_002_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																								
H1822	002	0	1	01	01	H1822_002_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																								
H1822	002	0	1	01	01	H1822_002_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	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										0.00	0.00	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											74.16	50	50	50				74.16	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
H1822	002	0	1	01	01	H1822_002_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																								
H1822	004	0	1	01	01	H1822_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																								
H1822	004	0	1	01	01	H1822_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																								
H1822	004	0	1	01	01	H1822_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					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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H1822	004	0	1	01	01	H1822_004_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											64.29	50	50	50				64.29	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
H1822	004	0	1	01	01	H1822_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																								
H1822	005	0	1	02	01	H1822_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1822	005	0	1	02	01	H1822_005_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																								
H1822	005	0	1	02	01	H1822_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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, 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
H1822	005	0	1	02	01	H1822_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											84.72	50	50	50				84.72	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
H1822	005	0	1	02	01	H1822_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																								
H1822	006	0	1	01	01	H1822_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1822	006	0	1	01	01	H1822_006_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																								
H1822	006	0	1	01	01	H1822_006_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											106.53	25	25	25				106.53	24	24	24										25	25	25				24	24	24			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
H1822	006	0	1	01	01	H1822_006_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											86.12	45	45	45				86.12	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
H1822	006	0	1	01	01	H1822_006_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																								
H1822	007	0	1	01	01	H1822_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1822	007	0	1	01	01	H1822_007_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																								
H1822	007	0	1	01	01	H1822_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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H1822	007	0	1	01	01	H1822_007_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											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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1822	007	0	1	01	01	H1822_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																								
H1846	005	0	1	04	01	H1846_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				59.41	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	70.00				35.00		35.00
H1846	005	0	1	04	01	H1846_005_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				89.99	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
H1846	005	0	1	04	01	H1846_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	31																				31																	31			31								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	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										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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				59.63	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	70.00				35.00		35.00
H1846	006	0	1	04	01	H1846_006_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				91.39	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
H1846	006	0	1	04	01	H1846_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	31																				31																	31			31								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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				42.73	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	70.00				35.00		35.00
H1846	007	0	1	04	01	H1846_007_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				83.56	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
H1846	007	0	1	04	01	H1846_007_0	7			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
H1862	005	0	1	02	01	H1862_005_0	5			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	005	0	1	02	01	H1862_005_0	5			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																								
H1862	005	0	1	02	01	H1862_005_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											152.82	25	25	25				152.82	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
H1862	005	0	1	02	01	H1862_005_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											44.41	38	38	38				43.24	37	37	37										38	38	38				37	37	37			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
H1862	005	0	1	02	01	H1862_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, Select Care Drugs																								
H1862	005	0	1	02	01	H1862_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	0.00				0.00				0.00			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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				195.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				186.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				185.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				173.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				181.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				152.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				176.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				190.00	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
H1889	025	0	1	04	01	H1889_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																								
H1889	025	0	1	04	01	H1889_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																								
H1889	025	0	1	04	01	H1889_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										25.00		75.00						75.00			65.00	25.00		25.00
H1889	025	0	1	04	01	H1889_025_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1889	025	0	1	04	01	H1889_025_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				152.00	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
H1889	027	0	1	04	01	H1889_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																								
H1889	027	0	1	04	01	H1889_027_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																								
H1889	027	0	1	04	01	H1889_027_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	027	0	1	04	01	H1889_027_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1889	027	0	1	04	01	H1889_027_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				191.00	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
H1894	008	0	1	02	01	H1894_008_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			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	02	01	H1894_008_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					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																								
H1894	008	0	1	02	01	H1894_008_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											57.04	25	25	25				45.63	20	20	20				20	20	20															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		35.00
H1894	008	0	1	02	01	H1894_008_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											69.63	25	25	25				69.63	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		35.00
H1894	008	0	1	02	01	H1894_008_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																								
H1894	008	0	1	02	01	H1894_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1894	011	0	1	01	01	H1894_011_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	1.00	2.00	3.00																			1.00	3.00	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																								
H1894	011	0	1	01	01	H1894_011_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.41	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1894	011	0	1	01	01	H1894_011_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				59.50	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
H1894	011	0	1	01	01	H1894_011_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				39.24	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
H1894	011	0	1	01	01	H1894_011_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, Select Care Drugs																								
H1894	011	0	1	01	01	H1894_011_0	6		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	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																								
H1914	001	0	1	04	01	H1914_001_0	5			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	5			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																								
H1914	001	0	1	04	01	H1914_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.27	25	25	25				154.27	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
H1914	001	0	1	04	01	H1914_001_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											76.26	40	40	40				74.36	39	39	39										40	40	40				39	39	39			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
H1914	001	0	1	04	01	H1914_001_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, Select Care Drugs																								
H1914	001	0	1	04	01	H1914_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	0.00				0.00				0.00			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	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	002	0	1	04	01	H1914_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1914	002	0	1	04	01	H1914_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.04	25	25	25				154.04	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
H1914	002	0	1	04	01	H1914_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											72.66	44	44	44				71.01	43	43	43										44	44	44				43	43	43			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
H1914	002	0	1	04	01	H1914_002_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, Select Care Drugs																								
H1914	002	0	1	04	01	H1914_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																								
H1914	007	0	1	04	01	H1914_007_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	007	0	1	04	01	H1914_007_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1914	007	0	1	04	01	H1914_007_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.07	25	25	25				158.07	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
H1914	007	0	1	04	01	H1914_007_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											67.66	40	40	40				65.96	39	39	39										40	40	40				39	39	39			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
H1914	007	0	1	04	01	H1914_007_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, Select Care Drugs																								
H1914	007	0	1	04	01	H1914_007_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	009	0	1	04	01	H1914_009_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					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																								
H1914	009	0	1	04	01	H1914_009_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1914	009	0	1	04	01	H1914_009_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											141.02	23	23	23				141.02	23	23	23										23	23	23				23	23	23			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
H1914	009	0	1	04	01	H1914_009_0	6			Non-Preferred Drug	3	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	200.00				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
H1914	009	0	1	04	01	H1914_009_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																								
H1914	009	0	1	04	01	H1914_009_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																								
H1914	010	0	1	04	01	H1914_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																								
H1914	010	0	1	04	01	H1914_010_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H1914	010	0	1	04	01	H1914_010_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.61	25	25	25				164.61	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
H1914	010	0	1	04	01	H1914_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											56.85	30	30	30				56.85	30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	010	0	1	04	01	H1914_010_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, Select Care Drugs																								
H1914	010	0	1	04	01	H1914_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																								
H1951	013	0	1	01	01	H1951_013_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
H1951	013	0	1	01	01	H1951_013_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
H1951	013	0	1	01	01	H1951_013_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		95.00	35.00		35.00
H1951	013	0	1	01	01	H1951_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		105.00	35.00		35.00
H1951	013	0	1	01	01	H1951_013_0	4			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
H1951	024	0	1	01	01	H1951_024_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
H1951	024	0	1	01	01	H1951_024_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
H1951	024	0	1	01	01	H1951_024_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		95.00	35.00		35.00
H1951	024	0	1	01	01	H1951_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	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		105.00	35.00		35.00
H1951	024	0	1	01	01	H1951_024_0	4			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
H1951	028	0	1	01	01	H1951_028_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
H1951	028	0	1	01	01	H1951_028_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
H1951	028	0	1	01	01	H1951_028_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		95.00	35.00		35.00
H1951	028	0	1	01	01	H1951_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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
H1951	028	0	1	01	01	H1951_028_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
H1951	038	0	1	01	01	H1951_038_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
H1951	038	0	1	01	01	H1951_038_0	4			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
H1951	038	0	1	01	01	H1951_038_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1951	038	0	1	01	01	H1951_038_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				53.00	35		35																								50		50				35		35			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
H1951	038	0	1	01	01	H1951_038_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
H1951	039	0	1	01	01	H1951_039_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
H1951	039	0	1	01	01	H1951_039_0	4			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
H1951	039	0	1	01	01	H1951_039_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H1951	039	0	1	01	01	H1951_039_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				57.00	35		35																								50		50				35		35			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
H1951	039	0	1	01	01	H1951_039_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
H1951	044	0	1	01	01	H1951_044_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, 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	7			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, 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	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00
H1951	044	0	1	01	01	H1951_044_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	35		35																								50		50				35		35			35			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
H1951	044	0	1	01	01	H1951_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H1951	044	0	1	01	01	H1951_044_0	7			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				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	047	1	1	01	01	H1951_047_1	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
H1951	047	1	1	01	01	H1951_047_1	4			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
H1951	047	1	1	01	01	H1951_047_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		95.00	35.00		35.00
H1951	047	1	1	01	01	H1951_047_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H1951	047	1	1	01	01	H1951_047_1	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
H1951	047	2	1	01	01	H1951_047_2	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
H1951	047	2	1	01	01	H1951_047_2	4			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
H1951	047	2	1	01	01	H1951_047_2	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		95.00	35.00		35.00
H1951	047	2	1	01	01	H1951_047_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H1951	047	2	1	01	01	H1951_047_2	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
H1951	048	1	1	01	01	H1951_048_1	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
H1951	048	1	1	01	01	H1951_048_1	4			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
H1951	048	1	1	01	01	H1951_048_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		95.00	35.00		35.00
H1951	048	1	1	01	01	H1951_048_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H1951	048	1	1	01	01	H1951_048_1	4			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
H1951	048	2	1	01	01	H1951_048_2	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
H1951	048	2	1	01	01	H1951_048_2	4			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
H1951	048	2	1	01	01	H1951_048_2	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		95.00	35.00		35.00
H1951	048	2	1	01	01	H1951_048_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H1951	048	2	1	01	01	H1951_048_2	4			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
H1951	049	1	1	01	01	H1951_049_1	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
H1951	049	1	1	01	01	H1951_049_1	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
H1951	049	1	1	01	01	H1951_049_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		95.00	35.00		35.00
H1951	049	1	1	01	01	H1951_049_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H1951	049	1	1	01	01	H1951_049_1	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
H1951	049	2	1	01	01	H1951_049_2	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
H1951	049	2	1	01	01	H1951_049_2	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
H1951	049	2	1	01	01	H1951_049_2	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		95.00	35.00		35.00
H1951	049	2	1	01	01	H1951_049_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H1951	049	2	1	01	01	H1951_049_2	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
H1951	049	3	1	01	01	H1951_049_3	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
H1951	049	3	1	01	01	H1951_049_3	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
H1951	049	3	1	01	01	H1951_049_3	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		95.00	35.00		35.00
H1951	049	3	1	01	01	H1951_049_3	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H1951	049	3	1	01	01	H1951_049_3	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
H1951	051	0	1	01	01	H1951_051_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
H1951	051	0	1	01	01	H1951_051_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
H1951	051	0	1	01	01	H1951_051_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		95.00	35.00		35.00
H1951	051	0	1	01	01	H1951_051_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H1951	051	0	1	01	01	H1951_051_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
H1951	052	0	1	01	01	H1951_052_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
H1951	052	0	1	01	01	H1951_052_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
H1951	052	0	1	01	01	H1951_052_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		95.00	35.00		35.00
H1951	052	0	1	01	01	H1951_052_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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
H1951	052	0	1	01	01	H1951_052_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
H1951	053	0	1	01	01	H1951_053_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
H1951	053	0	1	01	01	H1951_053_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
H1951	053	0	1	01	01	H1951_053_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		95.00	35.00		35.00
H1951	053	0	1	01	01	H1951_053_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H1951	053	0	1	01	01	H1951_053_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
H1951	054	0	1	01	01	H1951_054_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
H1951	054	0	1	01	01	H1951_054_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
H1951	054	0	1	01	01	H1951_054_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		95.00	35.00		35.00
H1951	054	0	1	01	01	H1951_054_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H1951	054	0	1	01	01	H1951_054_0	4			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
H1951	055	0	1	01	01	H1951_055_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
H1951	055	0	1	01	01	H1951_055_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
H1951	055	0	1	01	01	H1951_055_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		95.00	35.00		35.00
H1951	055	0	1	01	01	H1951_055_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H1951	055	0	1	01	01	H1951_055_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
H1951	058	0	1	01	01	H1951_058_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
H1951	058	0	1	01	01	H1951_058_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
H1951	058	0	1	01	01	H1951_058_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		95.00	35.00		35.00
H1951	058	0	1	01	01	H1951_058_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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
H1951	058	0	1	01	01	H1951_058_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
H1951	059	0	1	01	01	H1951_059_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
H1951	059	0	1	01	01	H1951_059_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
H1951	059	0	1	01	01	H1951_059_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		95.00	35.00		35.00
H1951	059	0	1	01	01	H1951_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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
H1951	059	0	1	01	01	H1951_059_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
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			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																								
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	47.00		141.00																											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			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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	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			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				197.00	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
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			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																								
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	47.00		141.00																											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			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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				197.00	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
H1961	014	3	1	02	01	H1961_014_3	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H1961	014	3	1	02	01	H1961_014_3	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						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			105.00	35.00		35.00
H1961	014	3	1	02	01	H1961_014_3	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1961	014	3	1	02	01	H1961_014_3	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				197.00	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
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			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																								
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	47.00		141.00																											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			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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				197.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											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			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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				181.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											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			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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				181.00	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
H1961	022	0	1	02	01	H1961_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																								
H1961	022	0	1	02	01	H1961_022_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																								
H1961	022	0	1	02	01	H1961_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						141.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00		75.00						75.00			75.00	25.00		25.00
H1961	022	0	1	02	01	H1961_022_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1961	022	0	1	02	01	H1961_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				158.00	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
H1961	023	0	1	02	01	H1961_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																								
H1961	023	0	1	02	01	H1961_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																								
H1961	023	0	1	02	01	H1961_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						141.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00		75.00						75.00			75.00	25.00		25.00
H1961	023	0	1	02	01	H1961_023_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1961	023	0	1	02	01	H1961_023_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				158.00	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
H1961	025	0	1	02	01	H1961_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																								
H1961	025	0	1	02	01	H1961_025_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																								
H1961	025	0	1	02	01	H1961_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						141.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00		75.00						75.00			75.00	25.00		25.00
H1961	025	0	1	02	01	H1961_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H1961	025	0	1	02	01	H1961_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				158.00	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
H1969	002	0	1	01	01	H1969_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								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
H1969	002	0	1	01	01	H1969_002_0	8			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					11.00	22.00	33.00											14.00	28.00	42.00				11.00	22.00	0.00				14.00				14.00			0.47	0.37		0.47	0.37	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00	11.00	22.00	33.00	14.00	28.00	42.00	11.00	22.00	0.00	14.00		14.00
H1969	002	0	1	01	01	H1969_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											58.28	25	25	25				58.28	22	22	22										25	25	25				22	22	22			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
H1969	002	0	1	01	01	H1969_002_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											63.12	43	43	43				63.12	40	40	40										43	43	43				40	40	40			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
H1969	002	0	1	01	01	H1969_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											979.88	33						979.88	33												33						33					33			33								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						2	2							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						2	2							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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1993	001	0	1	01	01	H1993_001_0	7			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	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										12.00	24.00	36.00				12.00	24.00	24.00				12.00		12.00
H1993	001	0	1	01	01	H1993_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	90.00																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	70.00				35.00		35.00
H1993	001	0	1	01	01	H1993_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		31	98.00																					98.00																		98.00				98.00		3.27			3.27			3.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00						35.00						35.00		35.00
H1993	001	0	1	01	01	H1993_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1103.92	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
H1993	001	0	1	01	01	H1993_001_0	7			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																								
H1993	007	0	1	01	01	H1993_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1993	007	0	1	01	01	H1993_007_0	7			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	7			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	56.00																28.00				28.00		0.93			0.93			0.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										28.00	56.00	84.00				28.00	56.00	56.00				28.00		28.00
H1993	007	0	1	01	01	H1993_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		31	75.00																					75.00																		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						35.00						35.00		35.00
H1993	007	0	1	01	01	H1993_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1103.92	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
H1993	007	0	1	01	01	H1993_007_0	7			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																								
H1993	008	0	1	01	01	H1993_008_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1993	008	0	1	01	01	H1993_008_0	7			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	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										15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1993	008	0	1	01	01	H1993_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	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, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1993	008	0	1	01	01	H1993_008_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		31	95.00																					95.00																		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						35.00						35.00		35.00
H1993	008	0	1	01	01	H1993_008_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				836.31	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
H1993	008	0	1	01	01	H1993_008_0	7			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																								
H1993	010	0	1	01	01	H1993_010_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1993	010	0	1	01	01	H1993_010_0	7			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	010	0	1	01	01	H1993_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	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, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1993	010	0	1	01	01	H1993_010_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		31	95.00																					95.00																		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						35.00						35.00		35.00
H1993	010	0	1	01	01	H1993_010_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1103.92	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
H1993	010	0	1	01	01	H1993_010_0	7			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																								
H1993	011	0	1	01	01	H1993_011_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1993	011	0	1	01	01	H1993_011_0	7			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	011	0	1	01	01	H1993_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	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, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1993	011	0	1	01	01	H1993_011_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		31	95.00																					95.00																		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						35.00						35.00		35.00
H1993	011	0	1	01	01	H1993_011_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1103.92	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
H1993	011	0	1	01	01	H1993_011_0	7			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																								
H1993	012	0	1	01	01	H1993_012_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1993	012	0	1	01	01	H1993_012_0	7			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	012	0	1	01	01	H1993_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	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, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1993	012	0	1	01	01	H1993_012_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		31	95.00																					95.00																		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						35.00						35.00		35.00
H1993	012	0	1	01	01	H1993_012_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1103.92	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
H1993	012	0	1	01	01	H1993_012_0	7			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																								
H1993	013	0	1	01	01	H1993_013_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H1993	013	0	1	01	01	H1993_013_0	7			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	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										15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1993	013	0	1	01	01	H1993_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	45.00	90.00	135.00																			40.00	90.00	90.00																45.00				45.00		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	70.00				35.00		35.00
H1993	013	0	1	01	01	H1993_013_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		31	100.00																					95.00																		100.00				100.00		3.33			3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00						35.00						35.00		35.00
H1993	013	0	1	01	01	H1993_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				836.31	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
H1993	013	0	1	01	01	H1993_013_0	7			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																								
H1994	001	0	1	01	01	H1994_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																								
H1994	001	0	1	01	01	H1994_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				10.00		0.33			0.17			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	001	0	1	01	01	H1994_001_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				37.74	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		35.00
H1994	001	0	1	01	01	H1994_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				94.75	22	22	22																		22	22	22															22			22								Preferred Generic, 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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				937.07	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	002	0	1	01	01	H1994_002_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																								
H1994	002	0	1	01	01	H1994_002_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				10.00		0.33			0.17			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	002	0	1	01	01	H1994_002_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				28.02	14	14	14																		14	14	14															14			14								Preferred Generic, 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	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				97.68	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
H1994	002	0	1	01	01	H1994_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1070.77	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	007	0	1	01	01	H1994_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																								
H1994	007	0	1	01	01	H1994_007_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 Drug, Specialty Tier																								
H1994	007	0	1	01	01	H1994_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	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	007	0	1	01	01	H1994_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
H1994	007	0	1	01	01	H1994_007_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				981.82	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	012	0	1	01	01	H1994_012_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																								
H1994	012	0	1	01	01	H1994_012_0	5			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	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																			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	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				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	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1081.04	33																				33																	33			33								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			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				15.00		0.50			0.17			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	017	0	1	01	01	H1994_017_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				28.28	14	14	14																		14	14	14															14			14								Preferred Generic, 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	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				95.36	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
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				834.15	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	021	0	1	01	01	H1994_021_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			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	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					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	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					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	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					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	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1461.26	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			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					5.00	10.00	15.00					3.00	6.00	9.00																6.00				6.00			0.20	0.17	0.10			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	022	0	1	01	01	H1994_022_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											32.70	21	21	21				1.00	16	16	16				16	16	16															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		35.00
H1994	022	0	1	01	01	H1994_022_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											89.54	26	26	26				1.00	21	21	21				21	21	21															26			26								Preferred Generic, Generic, Preferred Brand, Non-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											861.92	33						1113.70	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	025	0	1	01	01	H1994_025_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																								
H1994	025	0	1	01	01	H1994_025_0	5			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	025	0	1	01	01	H1994_025_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				68.52	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
H1994	025	0	1	01	01	H1994_025_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				99.68	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		35.00
H1994	025	0	1	01	01	H1994_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				906.20	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	027	0	1	01	01	H1994_027_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																								
H1994	027	0	1	01	01	H1994_027_0	4			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	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
H1994	027	0	1	01	01	H1994_027_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
H1994	027	0	1	01	01	H1994_027_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				45.14	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	028	0	1	01	01	H1994_028_0	5		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.52	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	028	0	1	01	01	H1994_028_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.56	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	028	0	1	01	01	H1994_028_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				107.77	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
H1994	028	0	1	01	01	H1994_028_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				110.36	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
H1994	028	0	1	01	01	H1994_028_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				562.50	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	029	0	1	01	01	H1994_029_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																								
H1994	029	0	1	01	01	H1994_029_0	5			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	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																			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	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				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	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				5145.29	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	030	0	1	01	01	H1994_030_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			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	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					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	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					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	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					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	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											827.06	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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	031	0	1	01	01	H1994_031_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																			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																								
H1994	031	0	1	01	01	H1994_031_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				77.25	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		35.00
H1994	031	0	1	01	01	H1994_031_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				98.39	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
H1994	031	0	1	01	01	H1994_031_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1113.70	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	034	0	1	01	01	H1994_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	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	034	0	1	01	01	H1994_034_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					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	034	0	1	01	01	H1994_034_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					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	034	0	1	01	01	H1994_034_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					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	034	0	1	01	01	H1994_034_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											827.06	33						1113.70	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	035	0	1	01	01	H1994_035_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																								
H1994	035	0	1	01	01	H1994_035_0	5			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				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	035	0	1	01	01	H1994_035_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				79.18	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
H1994	035	0	1	01	01	H1994_035_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				99.06	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
H1994	035	0	1	01	01	H1994_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1113.70	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	038	0	1	01	01	H1994_038_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	038	0	1	01	01	H1994_038_0	6			Generic	4	11	1	1	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											1.00	25	25	25				1.00	0	0	0				0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1994	038	0	1	01	01	H1994_038_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											68.47	25	25	25				56.56	20	20	20				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		35.00
H1994	038	0	1	01	01	H1994_038_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											94.80	35	35	35				78.92	30	30	30				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		35.00
H1994	038	0	1	01	01	H1994_038_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											943.66	30						1284.97	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H1997	013	0	1	01	01	H1997_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								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
H1997	013	0	1	01	01	H1997_013_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	39.00					7.00	14.00	21.00											13.00	26.00	39.00				7.00	14.00	0.00				13.00				13.00			0.43	0.23		0.43	0.23	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	39.00	7.00	14.00	21.00	13.00	26.00	39.00	7.00	14.00	0.00	13.00		13.00
H1997	013	0	1	01	01	H1997_013_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											43.54	25	25	25				43.54	22	22	22										25	25	25				22	22	22			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
H1997	013	0	1	01	01	H1997_013_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											62.15	43	43	43				62.15	40	40	40										43	43	43				40	40	40			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
H1997	013	0	1	01	01	H1997_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											642.88	30						642.88	30												30						30					30			30								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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	017	0	1	04	01	H2001_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				193.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				152.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	023	0	1	04	01	H2001_023_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				204.00	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
H2001	042	0	1	04	01	H2001_042_0	6			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																								
H2001	042	0	1	04	01	H2001_042_0	6			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				4.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2001	042	0	1	04	01	H2001_042_0	6			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				93.00	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
H2001	042	0	1	04	01	H2001_042_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				36.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H2001	042	0	1	04	01	H2001_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				168.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H2001	055	0	1	04	01	H2001_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																								
H2001	055	0	1	04	01	H2001_055_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																								
H2001	055	0	1	04	01	H2001_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										25.00		75.00						75.00			65.00	25.00		25.00
H2001	055	0	1	04	01	H2001_055_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	055	0	1	04	01	H2001_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				133.00	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
H2001	060	0	1	04	01	H2001_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																								
H2001	060	0	1	04	01	H2001_060_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																								
H2001	060	0	1	04	01	H2001_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										25.00		75.00						75.00			65.00	25.00		25.00
H2001	060	0	1	04	01	H2001_060_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	060	0	1	04	01	H2001_060_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				155.00	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
H2001	070	0	1	04	01	H2001_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																								
H2001	070	0	1	04	01	H2001_070_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																								
H2001	070	0	1	04	01	H2001_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										25.00		75.00						75.00			65.00	25.00		25.00
H2001	070	0	1	04	01	H2001_070_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	070	0	1	04	01	H2001_070_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				192.00	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
H2001	083	1	1	04	01	H2001_083_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																								
H2001	083	1	1	04	01	H2001_083_1	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	083	1	1	04	01	H2001_083_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
H2001	083	1	1	04	01	H2001_083_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	083	1	1	04	01	H2001_083_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				164.00	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
H2001	083	2	1	04	01	H2001_083_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																								
H2001	083	2	1	04	01	H2001_083_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																								
H2001	083	2	1	04	01	H2001_083_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
H2001	083	2	1	04	01	H2001_083_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	083	2	1	04	01	H2001_083_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				164.00	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
H2001	084	0	1	04	01	H2001_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																								
H2001	084	0	1	04	01	H2001_084_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																								
H2001	084	0	1	04	01	H2001_084_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	084	0	1	04	01	H2001_084_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	084	0	1	04	01	H2001_084_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
H2001	086	0	1	04	01	H2001_086_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	086	0	1	04	01	H2001_086_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																								
H2001	086	0	1	04	01	H2001_086_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	086	0	1	04	01	H2001_086_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	086	0	1	04	01	H2001_086_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				180.00	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
H2001	087	0	1	04	01	H2001_087_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	087	0	1	04	01	H2001_087_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	087	0	1	04	01	H2001_087_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	087	0	1	04	01	H2001_087_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	087	0	1	04	01	H2001_087_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
H2001	088	1	1	04	01	H2001_088_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																								
H2001	088	1	1	04	01	H2001_088_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																								
H2001	088	1	1	04	01	H2001_088_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
H2001	088	1	1	04	01	H2001_088_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	088	1	1	04	01	H2001_088_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
H2001	088	2	1	04	01	H2001_088_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																								
H2001	088	2	1	04	01	H2001_088_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																								
H2001	088	2	1	04	01	H2001_088_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
H2001	088	2	1	04	01	H2001_088_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	088	2	1	04	01	H2001_088_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
H2001	089	0	1	04	01	H2001_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																								
H2001	089	0	1	04	01	H2001_089_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	089	0	1	04	01	H2001_089_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	089	0	1	04	01	H2001_089_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	089	0	1	04	01	H2001_089_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H2001	090	0	1	04	01	H2001_090_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	090	0	1	04	01	H2001_090_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																								
H2001	090	0	1	04	01	H2001_090_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	090	0	1	04	01	H2001_090_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	090	0	1	04	01	H2001_090_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H2001	091	0	1	04	01	H2001_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																								
H2001	091	0	1	04	01	H2001_091_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	091	0	1	04	01	H2001_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
H2001	091	0	1	04	01	H2001_091_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	091	0	1	04	01	H2001_091_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H2001	092	0	1	04	01	H2001_092_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	092	0	1	04	01	H2001_092_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																								
H2001	092	0	1	04	01	H2001_092_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	092	0	1	04	01	H2001_092_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	092	0	1	04	01	H2001_092_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
H2001	093	0	1	04	01	H2001_093_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	093	0	1	04	01	H2001_093_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																								
H2001	093	0	1	04	01	H2001_093_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	093	0	1	04	01	H2001_093_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	093	0	1	04	01	H2001_093_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				213.00	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
H2001	094	0	1	04	01	H2001_094_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	094	0	1	04	01	H2001_094_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																								
H2001	094	0	1	04	01	H2001_094_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	094	0	1	04	01	H2001_094_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	094	0	1	04	01	H2001_094_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				224.00	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
H2001	095	0	1	04	01	H2001_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																								
H2001	095	0	1	04	01	H2001_095_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	095	0	1	04	01	H2001_095_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	095	0	1	04	01	H2001_095_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	095	0	1	04	01	H2001_095_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H2001	096	0	1	04	01	H2001_096_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	096	0	1	04	01	H2001_096_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																								
H2001	096	0	1	04	01	H2001_096_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	096	0	1	04	01	H2001_096_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	096	0	1	04	01	H2001_096_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H2001	097	0	1	04	01	H2001_097_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	097	0	1	04	01	H2001_097_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																								
H2001	097	0	1	04	01	H2001_097_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	097	0	1	04	01	H2001_097_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	097	0	1	04	01	H2001_097_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				192.00	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
H2001	098	0	1	04	01	H2001_098_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	098	0	1	04	01	H2001_098_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																								
H2001	098	0	1	04	01	H2001_098_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	098	0	1	04	01	H2001_098_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	098	0	1	04	01	H2001_098_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H2001	100	0	1	04	01	H2001_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																								
H2001	100	0	1	04	01	H2001_100_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	100	0	1	04	01	H2001_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
H2001	100	0	1	04	01	H2001_100_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	100	0	1	04	01	H2001_100_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H2001	101	0	1	04	01	H2001_101_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	101	0	1	04	01	H2001_101_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																								
H2001	101	0	1	04	01	H2001_101_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	101	0	1	04	01	H2001_101_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	101	0	1	04	01	H2001_101_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
H2001	102	0	1	04	01	H2001_102_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	102	0	1	04	01	H2001_102_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																								
H2001	102	0	1	04	01	H2001_102_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	102	0	1	04	01	H2001_102_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	102	0	1	04	01	H2001_102_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H2001	104	0	1	04	01	H2001_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																								
H2001	104	0	1	04	01	H2001_104_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																								
H2001	104	0	1	04	01	H2001_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
H2001	104	0	1	04	01	H2001_104_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	104	0	1	04	01	H2001_104_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				200.00	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
H2001	105	0	1	04	01	H2001_105_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	105	0	1	04	01	H2001_105_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																								
H2001	105	0	1	04	01	H2001_105_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	105	0	1	04	01	H2001_105_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	105	0	1	04	01	H2001_105_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
H2001	108	0	1	04	01	H2001_108_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	108	0	1	04	01	H2001_108_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																								
H2001	108	0	1	04	01	H2001_108_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	108	0	1	04	01	H2001_108_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	108	0	1	04	01	H2001_108_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
H2001	109	0	1	04	01	H2001_109_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	109	0	1	04	01	H2001_109_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																								
H2001	109	0	1	04	01	H2001_109_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	109	0	1	04	01	H2001_109_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	109	0	1	04	01	H2001_109_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				212.00	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
H2001	110	0	1	04	01	H2001_110_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	110	0	1	04	01	H2001_110_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																								
H2001	110	0	1	04	01	H2001_110_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	110	0	1	04	01	H2001_110_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	110	0	1	04	01	H2001_110_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				156.00	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
H2001	111	0	1	04	01	H2001_111_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	111	0	1	04	01	H2001_111_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																								
H2001	111	0	1	04	01	H2001_111_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	111	0	1	04	01	H2001_111_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	111	0	1	04	01	H2001_111_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				206.00	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
H2001	113	0	1	04	01	H2001_113_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	113	0	1	04	01	H2001_113_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	113	0	1	04	01	H2001_113_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	113	0	1	04	01	H2001_113_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	113	0	1	04	01	H2001_113_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
H2001	115	0	1	04	01	H2001_115_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	115	0	1	04	01	H2001_115_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																								
H2001	115	0	1	04	01	H2001_115_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	115	0	1	04	01	H2001_115_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	115	0	1	04	01	H2001_115_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
H2001	116	0	1	04	01	H2001_116_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	116	0	1	04	01	H2001_116_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	116	0	1	04	01	H2001_116_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	116	0	1	04	01	H2001_116_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	116	0	1	04	01	H2001_116_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				143.00	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
H2001	117	0	1	04	01	H2001_117_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	117	0	1	04	01	H2001_117_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	117	0	1	04	01	H2001_117_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	117	0	1	04	01	H2001_117_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	117	0	1	04	01	H2001_117_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H2001	119	0	1	04	01	H2001_119_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	119	0	1	04	01	H2001_119_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	119	0	1	04	01	H2001_119_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	119	0	1	04	01	H2001_119_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	119	0	1	04	01	H2001_119_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				143.00	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
H2001	120	0	1	04	01	H2001_120_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	120	0	1	04	01	H2001_120_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	120	0	1	04	01	H2001_120_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	120	0	1	04	01	H2001_120_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	120	0	1	04	01	H2001_120_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				162.00	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
H2001	121	0	1	04	01	H2001_121_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	121	0	1	04	01	H2001_121_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	121	0	1	04	01	H2001_121_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	121	0	1	04	01	H2001_121_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	121	0	1	04	01	H2001_121_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				139.00	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
H2001	122	0	1	04	01	H2001_122_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	122	0	1	04	01	H2001_122_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	122	0	1	04	01	H2001_122_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	122	0	1	04	01	H2001_122_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	122	0	1	04	01	H2001_122_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				149.00	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
H2001	123	0	1	04	01	H2001_123_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	123	0	1	04	01	H2001_123_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																								
H2001	123	0	1	04	01	H2001_123_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	123	0	1	04	01	H2001_123_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	123	0	1	04	01	H2001_123_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H2001	125	0	1	04	01	H2001_125_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	125	0	1	04	01	H2001_125_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	125	0	1	04	01	H2001_125_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	125	0	1	04	01	H2001_125_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	125	0	1	04	01	H2001_125_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				196.00	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
H2001	127	0	1	04	01	H2001_127_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	127	0	1	04	01	H2001_127_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																								
H2001	127	0	1	04	01	H2001_127_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	127	0	1	04	01	H2001_127_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	127	0	1	04	01	H2001_127_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H2001	128	0	1	04	01	H2001_128_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	128	0	1	04	01	H2001_128_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	128	0	1	04	01	H2001_128_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	128	0	1	04	01	H2001_128_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	128	0	1	04	01	H2001_128_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
H2001	131	0	1	04	01	H2001_131_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	131	0	1	04	01	H2001_131_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	131	0	1	04	01	H2001_131_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	131	0	1	04	01	H2001_131_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	131	0	1	04	01	H2001_131_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H2001	132	0	1	04	01	H2001_132_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	132	0	1	04	01	H2001_132_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	132	0	1	04	01	H2001_132_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	132	0	1	04	01	H2001_132_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	132	0	1	04	01	H2001_132_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
H2001	133	0	1	04	01	H2001_133_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	133	0	1	04	01	H2001_133_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	133	0	1	04	01	H2001_133_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
H2001	133	0	1	04	01	H2001_133_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	133	0	1	04	01	H2001_133_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H2001	136	0	1	04	01	H2001_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																								
H2001	136	0	1	04	01	H2001_136_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	136	0	1	04	01	H2001_136_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	136	0	1	04	01	H2001_136_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	136	0	1	04	01	H2001_136_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				200.00	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
H2001	137	0	1	04	01	H2001_137_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	137	0	1	04	01	H2001_137_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	137	0	1	04	01	H2001_137_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	137	0	1	04	01	H2001_137_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	137	0	1	04	01	H2001_137_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				153.00	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
H2001	138	0	1	04	01	H2001_138_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	138	0	1	04	01	H2001_138_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																								
H2001	138	0	1	04	01	H2001_138_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	138	0	1	04	01	H2001_138_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2001	138	0	1	04	01	H2001_138_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				191.00	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
H2029	001	0	1	04	01	H2029_001_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
H2029	001	0	1	04	01	H2029_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																									0.00		0.00				0.00		0.00				0.00				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	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, 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	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	25		25																								25		25				25		25			25			25								Preferred 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	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
H2029	001	0	1	04	01	H2029_001_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
H2032	001	0	1	04	01	H2032_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								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
H2032	001	0	1	04	01	H2032_001_0	10			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	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					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	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	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	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																								
H2032	002	0	1	04	01	H2032_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								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
H2032	002	0	1	04	01	H2032_002_0	10			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	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					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	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	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	10			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																								
H2032	003	0	1	04	01	H2032_003_0	10			Preferred Generic	4	11	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										5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H2032	003	0	1	04	01	H2032_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
H2032	003	0	1	04	01	H2032_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
H2032	003	0	1	04	01	H2032_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
H2032	003	0	1	04	01	H2032_003_0	10			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																								
H2032	004	0	1	04	01	H2032_004_0	9			Preferred Generic	4	11	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										5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H2032	004	0	1	04	01	H2032_004_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					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	004	0	1	04	01	H2032_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	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	004	0	1	04	01	H2032_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								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	004	0	1	04	01	H2032_004_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																								
H2041	001	0	1	01	01	H2041_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2041	001	0	1	01	01	H2041_001_0	7			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
H2041	001	0	1	01	01	H2041_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H2041	001	0	1	01	01	H2041_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				45.00	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
H2041	001	0	1	01	01	H2041_001_0	7			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
H2041	002	0	1	01	01	H2041_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2041	002	0	1	01	01	H2041_002_0	7			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
H2041	002	0	1	01	01	H2041_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				63.00	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
H2041	002	0	1	01	01	H2041_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				48.00	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
H2041	002	0	1	01	01	H2041_002_0	7			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
H2041	003	0	1	01	01	H2041_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2041	003	0	1	01	01	H2041_003_0	7			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
H2041	003	0	1	01	01	H2041_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H2041	003	0	1	01	01	H2041_003_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				45.00	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
H2041	003	0	1	01	01	H2041_003_0	7			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
H2041	004	0	1	01	01	H2041_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2041	004	0	1	01	01	H2041_004_0	7			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
H2041	004	0	1	01	01	H2041_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				63.00	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
H2041	004	0	1	01	01	H2041_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				48.00	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
H2041	004	0	1	01	01	H2041_004_0	7			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
H2041	005	0	1	01	01	H2041_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2041	005	0	1	01	01	H2041_005_0	7			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
H2041	005	0	1	01	01	H2041_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H2041	005	0	1	01	01	H2041_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				45.00	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
H2041	005	0	1	01	01	H2041_005_0	7			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
H2041	006	0	1	01	01	H2041_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2041	006	0	1	01	01	H2041_006_0	7			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				9.00		9.00
H2041	006	0	1	01	01	H2041_006_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				63.00	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
H2041	006	0	1	01	01	H2041_006_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				48.00	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
H2041	006	0	1	01	01	H2041_006_0	7			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
H2056	003	0	1	02	01	H2056_003_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2056	003	0	1	02	01	H2056_003_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2056	003	0	1	02	01	H2056_003_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.16	25	25	25				82.11	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
H2056	003	0	1	02	01	H2056_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.12	35	35	35				28.46	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
H2056	003	0	1	02	01	H2056_003_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1037.32	33						1209.66	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
H2056	004	0	1	02	01	H2056_004_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2056	004	0	1	02	01	H2056_004_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2056	004	0	1	02	01	H2056_004_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.00	24	24	24				99.31	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
H2056	004	0	1	02	01	H2056_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.46	25	25	25				37.49	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
H2056	004	0	1	02	01	H2056_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											871.11	25						750.08	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
H2056	005	0	1	02	01	H2056_005_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2056	005	0	1	02	01	H2056_005_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2056	005	0	1	02	01	H2056_005_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.10	25	25	25				72.47	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
H2056	005	0	1	02	01	H2056_005_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.88	35	35	35				27.84	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
H2056	005	0	1	02	01	H2056_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1243.59	33						1328.07	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
H2108	022	0	1	01	01	H2108_022_0	4			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
H2108	022	0	1	01	01	H2108_022_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H2108	022	0	1	01	01	H2108_022_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											799.79	33						723.92	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
H2108	029	0	1	01	01	H2108_029_0	4			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, 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	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H2108	029	0	1	01	01	H2108_029_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											572.10	33						425.30	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	4			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	4			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, 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	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H2108	030	0	1	01	01	H2108_030_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											602.05	33						335.62	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	4			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	4			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
H2108	036	0	1	01	01	H2108_036_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H2108	036	0	1	01	01	H2108_036_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											777.76	33						840.99	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
H2108	040	0	1	01	01	H2108_040_0	4			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
H2108	040	0	1	01	01	H2108_040_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H2108	040	0	1	01	01	H2108_040_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											790.69	33						768.89	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
H2108	042	1	1	01	01	H2108_042_1	4			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
H2108	042	1	1	01	01	H2108_042_1	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H2108	042	1	1	01	01	H2108_042_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											781.14	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
H2108	042	2	1	01	01	H2108_042_2	4			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
H2108	042	2	1	01	01	H2108_042_2	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H2108	042	2	1	01	01	H2108_042_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											781.14	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
H2117	001	0	1	04	01	H2117_001_0	5			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	5			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																								
H2117	001	0	1	04	01	H2117_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.93	25	25	25				157.93	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
H2117	001	0	1	04	01	H2117_001_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											49.53	45	45	45				49.53	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
H2117	001	0	1	04	01	H2117_001_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, Select Care Drugs																								
H2117	001	0	1	04	01	H2117_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2117	002	0	1	04	01	H2117_002_0	5		N	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2117	002	0	1	04	01	H2117_002_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2117	002	0	1	04	01	H2117_002_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											124.70	22	22	22				124.70	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
H2117	002	0	1	04	01	H2117_002_0	5		N	Non-Preferred Drug	3	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	200.00				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
H2117	002	0	1	04	01	H2117_002_0	5		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, Select Care Drugs																								
H2117	002	0	1	04	01	H2117_002_0	5		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	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2117	005	0	1	04	01	H2117_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2117	005	0	1	04	01	H2117_005_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H2117	005	0	1	04	01	H2117_005_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.12	25	25	25				155.12	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
H2117	005	0	1	04	01	H2117_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											62.99	37	37	37				62.99	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
H2117	005	0	1	04	01	H2117_005_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, Select Care Drugs																								
H2117	005	0	1	04	01	H2117_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																								
H2128	002	0	1	04	01	H2128_002_0	5			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	5			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																								
H2128	002	0	1	04	01	H2128_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											160.19	25	25	25				160.19	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
H2128	002	0	1	04	01	H2128_002_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											66.83	39	39	39				66.83	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
H2128	002	0	1	04	01	H2128_002_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, Select Care Drugs																								
H2128	002	0	1	04	01	H2128_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	0.00				0.00				0.00			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	5			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	5			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																								
H2128	004	0	1	04	01	H2128_004_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.89	25	25	25				161.89	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
H2128	004	0	1	04	01	H2128_004_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											59.94	31	31	31				58.01	30	30	30										31	31	31				30	30	30			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
H2128	004	0	1	04	01	H2128_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, Select Care Drugs																								
H2128	004	0	1	04	01	H2128_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		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2128	005	0	1	04	01	H2128_005_0	5		N	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					4.00	8.00	12.00											19.00	38.00	57.00				4.00	8.00	0.00				19.00				19.00			0.63	0.13		0.63	0.13	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2128	005	0	1	04	01	H2128_005_0	5		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					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.5		0.67	0.5	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2128	005	0	1	04	01	H2128_005_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											122.18	21	21	21				116.36	20	20	20										21	21	21				20	20	20			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
H2128	005	0	1	04	01	H2128_005_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.98	36	36	36				40.98	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
H2128	005	0	1	04	01	H2128_005_0	5		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, Select Care Drugs																								
H2128	005	0	1	04	01	H2128_005_0	5		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	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2128	006	0	1	04	01	H2128_006_0	5		N	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					11.00	22.00	33.00											19.00	38.00	57.00				11.00	22.00	0.00				19.00				19.00			0.63	0.37		0.63	0.37	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2128	006	0	1	04	01	H2128_006_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2128	006	0	1	04	01	H2128_006_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											118.93	20	20	20				118.93	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
H2128	006	0	1	04	01	H2128_006_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											33.85	37	37	37				32.94	36	36	36										37	37	37				36	36	36			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
H2128	006	0	1	04	01	H2128_006_0	5		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, Select Care Drugs																								
H2128	006	0	1	04	01	H2128_006_0	5		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	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	7		N	Preferred Generic	4	01	3	2	1	1	111		10	100		1	30	60	90				2	2			90					10	31	2.00	4.00	6.00																					6.00																	2.00			2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2.00	4.00	6.00						6.00				2.00		2.00
H2168	001	0	1	01	01	H2168_001_0	7		N	Generic	4	01	1	2	2	1	111		10	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, Select Care Drugs										5.00	10.00	15.00						15.00				5.00		5.00
H2168	001	0	1	01	01	H2168_001_0	7		N	Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				2	2			90					10	31				130.52	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
H2168	001	0	1	01	01	H2168_001_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	100		1	30	60	90				2	2			90					10	31				97.92	33	33	33																				33																33		33								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
H2168	001	0	1	01	01	H2168_001_0	7		N	Specialty Tier	4	10	1	1	5	1	010		10	000		1	30															10	31				493.53	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H2168	001	0	1	01	01	H2168_001_0	7		N	Select Care Drugs	4	01	1	1	6	1	111		10	100		1	30	60	90				1	2			90					10	31				0.40	15	15	15																				15																15		15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2168	002	0	1	01	01	H2168_002_0	6		N	Preferred Generic	4	01	3	2	1	1	111		10	100		1	30	60	90				2	2			90					10	31	2.00	4.00	6.00																					6.00																	2.00			2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2.00	4.00	6.00						6.00				2.00		2.00
H2168	002	0	1	01	01	H2168_002_0	6		N	Generic	4	01	1	2	2	1	111		10	100		1	30	60	90				2	2			90					10	31	3.00	6.00	9.00																					9.00																	3.00			3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										3.00	6.00	9.00						9.00				3.00		3.00
H2168	002	0	1	01	01	H2168_002_0	6		N	Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				2	2			90					10	31				112.85	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
H2168	002	0	1	01	01	H2168_002_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	100		1	30	60	90				2	2			90					10	31				77.77	27	27	27																				27																27		27								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
H2168	002	0	1	01	01	H2168_002_0	6		N	Specialty Tier	4	10	1	1	5	1	010		10	000		1	30															10	31				411.54	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H2168	002	0	1	01	01	H2168_002_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		10	100		1	30	60	90				1	2			90					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 Drug, Specialty Tier, Select Care Drugs																								
H2168	003	0	1	01	01	H2168_003_0	7		N	Preferred Generic	4	01	3	2	1	1	111		10	100		1	30	60	90				2	2			90					10	31	2.00	4.00	6.00																					6.00																	2.00			2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2.00	4.00	6.00						6.00				2.00		2.00
H2168	003	0	1	01	01	H2168_003_0	7		N	Generic	4	01	1	2	2	1	111		10	100		1	30	60	90				2	2			90					10	31	8.00	16.00	24.00																					24.00																	8.00			8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										8.00	16.00	24.00						24.00				8.00		8.00
H2168	003	0	1	01	01	H2168_003_0	7		N	Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				2	2			90					10	31				141.82	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
H2168	003	0	1	01	01	H2168_003_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	100		1	30	60	90				2	2			90					10	31				99.59	30	30	30																				30																30		30								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
H2168	003	0	1	01	01	H2168_003_0	7		N	Specialty Tier	4	10	1	1	5	1	010		10	000		1	30															10	31				536.91	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H2168	003	0	1	01	01	H2168_003_0	7		N	Select Care Drugs	4	01	1	1	6	1	111		10	100		1	30	60	90				1	2			90					10	31				0.25	15	15	15																				15																15		15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2168	004	0	1	01	01	H2168_004_0	6			Preferred Generic	4	01	3	2	1	1	111		10	100		1	30	60	90				2	2			90					10	31	2.00	4.00	6.00																					6.00																	2.00			2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2.00	4.00	6.00						6.00				2.00		2.00
H2168	004	0	1	01	01	H2168_004_0	6			Generic	4	01	1	2	2	1	111		10	100		1	30	60	90				2	2			90					10	31	9.00	18.00	27.00																					27.00																	9.00			9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										9.00	18.00	27.00						27.00				9.00		9.00
H2168	004	0	1	01	01	H2168_004_0	6			Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				2	2			90					10	31				153.76	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
H2168	004	0	1	01	01	H2168_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		10	100		1	30	60	90				2	2			90					10	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										35.00	70.00	105.00						105.00				35.00		35.00
H2168	004	0	1	01	01	H2168_004_0	6			Specialty Tier	4	10	1	1	5	1	010		10	000		1	30															10	31				558.54	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H2168	004	0	1	01	01	H2168_004_0	6			Select Care Drugs	4	01	1	2	6	1	111		10	100		1	30	60	90				1	2			90					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 Drug, Specialty Tier, Select Care Drugs																								
H2172	001	0	1	02	01	H2172_001_0	8			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										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	8			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										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	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					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										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	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	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										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	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	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	8			Vaccines	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																								
H2172	002	0	1	02	01	H2172_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								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										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	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					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										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	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					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										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	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	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										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	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										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	7			Vaccines	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																								
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										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										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										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										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										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	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																								
H2172	004	0	1	02	01	H2172_004_0	8			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										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	8			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										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	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					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										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	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	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										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	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	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	8			Vaccines	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																								
H2172	006	0	1	01	01	H2172_006_0	8			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										10.00	20.00	30.00	3.00	6.00	9.00	3.00	0.00	0.00				10.00		10.00
H2172	006	0	1	01	01	H2172_006_0	8			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					14.00	28.00	42.00					14.00	0.00	0.00																20.00				20.00			0.66	0.46	0.46			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	14.00	28.00	42.00	14.00	0.00	0.00				20.00		20.00
H2172	006	0	1	01	01	H2172_006_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					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										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	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	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										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	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	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	8			Vaccines	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																								
H2172	008	0	1	02	01	H2172_008_0	7			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										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	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					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										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	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					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										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	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	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										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	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										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	7			Vaccines	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																								
H2172	009	0	1	02	01	H2172_009_0	7			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										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	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					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										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	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	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										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	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	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										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	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										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	7			Vaccines	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																								
H2172	010	0	1	02	01	H2172_010_0	7			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										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	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					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										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	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	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										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	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	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										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	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										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	7			Vaccines	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																								
H2172	011	0	1	01	01	H2172_011_0	8			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										10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	011	0	1	01	01	H2172_011_0	8			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					14.00	28.00	42.00					14.00	0.00	0.00																20.00				20.00			0.66	0.46	0.46			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	14.00	28.00	42.00	14.00	0.00	0.00				20.00		20.00
H2172	011	0	1	01	01	H2172_011_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					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										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	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	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										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	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	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	8			Vaccines	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																								
H2172	012	0	1	02	01	H2172_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								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										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	8			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										20.00	40.00	60.00	7.00	14.00	21.00	7.00	0.00	0.00				20.00		20.00
H2172	012	0	1	02	01	H2172_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					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										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	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					95.00	190.00	190.00																100.00				100.00			3.33	3.16	3.16			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	8			Vaccines	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																								
H2172	013	0	1	02	01	H2172_013_0	7			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										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	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					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										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	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	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										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	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	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										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	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										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	7			Vaccines	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																								
H2172	014	0	1	02	01	H2172_014_0	7			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										10.00	20.00	30.00	5.00	10.00	15.00	5.00	0.00	0.00				10.00		10.00
H2172	014	0	1	02	01	H2172_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					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										20.00	40.00	60.00	15.00	30.00	45.00	15.00	0.00	0.00				20.00		20.00
H2172	014	0	1	02	01	H2172_014_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					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.56	1.56	1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00
H2172	014	0	1	02	01	H2172_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	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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	014	0	1	02	01	H2172_014_0	7			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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	014	0	1	02	01	H2172_014_0	7			Vaccines	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																								
H2185	003	0	1	02	01	H2185_003_0	6			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																								
H2185	003	0	1	02	01	H2185_003_0	6			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																								
H2185	003	0	1	02	01	H2185_003_0	6			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
H2185	003	0	1	02	01	H2185_003_0	6			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
H2185	003	0	1	02	01	H2185_003_0	6			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																								
H2225	001	0	1	01	01	H2225_001_0	7		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 Drug, Specialty Tier																								
H2225	001	0	1	01	01	H2225_001_0	7		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 Drug, Specialty Tier																								
H2225	001	0	1	01	01	H2225_001_0	7		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 Drug, 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	7		N	Non-Preferred Drug	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 Drug, 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	7		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 Drug, Specialty Tier										35.00						35.00						35.00		35.00
H2230	002	0	1	04	01	H2230_002_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					0.00	0.00	0.00					0.00	0.00	0.00																6.00				6.00			0.20	0.00	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	0.00	0.00	0.00				6.00		6.00
H2230	002	0	1	04	01	H2230_002_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					5.00	10.00	15.00					5.00	10.00	10.00																10.00				10.00			0.33	0.17	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	5.00	10.00	10.00				10.00		10.00
H2230	002	0	1	04	01	H2230_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					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
H2230	002	0	1	04	01	H2230_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					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
H2230	002	0	1	04	01	H2230_002_0	4			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
H2230	017	0	1	04	01	H2230_017_0	5			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	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
H2230	017	0	1	04	01	H2230_017_0	5			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					10.00	20.00	20.00																20.00				20.00			0.67	0.33	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	10.00	20.00	20.00				20.00		20.00
H2230	017	0	1	04	01	H2230_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											101.03	24	24	24				101.24	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	70.00				35.00		35.00
H2230	017	0	1	04	01	H2230_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											99.28	49	49	49				51.95	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	70.00				35.00		35.00
H2230	017	0	1	04	01	H2230_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
H2230	018	1	1	04	01	H2230_018_1	4			Preferred Generic	4	11	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				8.00			0.27	0.00	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	0.00	0.00	0.00				8.00		8.00
H2230	018	1	1	04	01	H2230_018_1	4			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					6.00	12.00	18.00					6.00	12.00	12.00																12.00				12.00			0.40	0.20	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	6.00	12.00	12.00				12.00		12.00
H2230	018	1	1	04	01	H2230_018_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					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
H2230	018	1	1	04	01	H2230_018_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					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
H2230	018	1	1	04	01	H2230_018_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
H2230	018	2	1	04	01	H2230_018_2	4			Preferred Generic	4	11	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				8.00			0.27	0.00	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	0.00	0.00	0.00				8.00		8.00
H2230	018	2	1	04	01	H2230_018_2	4			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					6.00	12.00	18.00					6.00	12.00	12.00																12.00				12.00			0.40	0.20	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	6.00	12.00	12.00				12.00		12.00
H2230	018	2	1	04	01	H2230_018_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	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
H2230	018	2	1	04	01	H2230_018_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	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
H2230	018	2	1	04	01	H2230_018_2	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
H2235	001	0	1	01	01	H2235_001_0	10			Preferred Generic	4	01	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 Brand, Specialty Tier, Select Care Drugs																								
H2235	001	0	1	01	01	H2235_001_0	10			Generic	4	01	3	2	2	1	111		01	100		1	30	60	100				1	2			100				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, Select Care Drugs										3.00	6.00	9.00						0.00				3.00		3.00
H2235	001	0	1	01	01	H2235_001_0	10			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	100				1	2			100				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, Select Care Drugs										35.00	70.00	105.00						95.00				35.00		35.00
H2235	001	0	1	01	01	H2235_001_0	10			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				96.25	31	31	31																				31															31			31								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
H2235	001	0	1	01	01	H2235_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				463.04	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H2235	001	0	1	01	01	H2235_001_0	10			Select Care Drugs	4	10	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																								
H2235	002	0	1	01	01	H2235_002_0	9			Preferred Generic	4	01	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 Brand, Specialty Tier, Select Care Drugs																								
H2235	002	0	1	01	01	H2235_002_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																					0.00																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	30.00						0.00				10.00		10.00
H2235	002	0	1	01	01	H2235_002_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																					125.00																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
H2235	002	0	1	01	01	H2235_002_0	9			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				94.94	40	40	40																				40															40			40								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
H2235	002	0	1	01	01	H2235_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				800.92	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H2235	002	0	1	01	01	H2235_002_0	9			Select Care Drugs	4	10	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																								
H2235	003	0	1	01	01	H2235_003_0	10			Preferred Generic	4	01	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 Brand, Specialty Tier, Select Care Drugs																								
H2235	003	0	1	01	01	H2235_003_0	10			Generic	4	01	3	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 Brand, Specialty Tier, Select Care Drugs										0.00	0.00	0.00						0.00				0.00		0.00
H2235	003	0	1	01	01	H2235_003_0	10			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	100				1	2			100				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, Select Care Drugs										30.00	60.00	90.00						80.00				30.00		30.00
H2235	003	0	1	01	01	H2235_003_0	10			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				97.89	31	31	31																				31															31			31								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
H2235	003	0	1	01	01	H2235_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				509.35	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H2235	003	0	1	01	01	H2235_003_0	10			Select Care Drugs	4	10	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																								
H2246	018	0	1	04	01	H2246_018_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																								
H2246	018	0	1	04	01	H2246_018_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				10.00		0.33			0.17			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2246	018	0	1	04	01	H2246_018_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				37.44	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
H2246	018	0	1	04	01	H2246_018_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				93.28	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		35.00
H2246	018	0	1	04	01	H2246_018_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				726.87	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2246	019	0	1	04	01	H2246_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	0.00	0.00	0.00																			0.00	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	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	16.00	24.00																			10.00	16.00	24.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2246	019	0	1	04	01	H2246_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	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	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
H2246	019	0	1	04	01	H2246_019_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				339.48	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2246	026	0	1	04	01	H2246_026_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																								
H2246	026	0	1	04	01	H2246_026_0	5			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																								
H2246	026	0	1	04	01	H2246_026_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				67.56	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
H2246	026	0	1	04	01	H2246_026_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				98.93	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		35.00
H2246	026	0	1	04	01	H2246_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				906.20	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2246	032	0	1	04	01	H2246_032_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																								
H2246	032	0	1	04	01	H2246_032_0	5			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				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2246	032	0	1	04	01	H2246_032_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																			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	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				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	5			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	5			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										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	5			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										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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				63.45	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.09	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	001	1	1	01	01	H2256_001_1	5			Vaccines	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																								
H2256	001	2	1	01	01	H2256_001_2	5			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										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	5			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										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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				63.45	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.09	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	001	2	1	01	01	H2256_001_2	5			Vaccines	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																								
H2256	001	6	1	01	01	H2256_001_6	5			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										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	5			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										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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				63.45	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.09	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	001	6	1	01	01	H2256_001_6	5			Vaccines	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																								
H2256	015	1	1	01	01	H2256_015_1	5			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										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	5			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										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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				60.55	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				49.25	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	015	1	1	01	01	H2256_015_1	5			Vaccines	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																								
H2256	015	2	1	01	01	H2256_015_2	5			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										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	5			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										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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				60.55	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				49.25	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	015	2	1	01	01	H2256_015_2	5			Vaccines	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																								
H2256	015	6	1	01	01	H2256_015_6	5			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										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	5			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										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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				60.55	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				49.25	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	015	6	1	01	01	H2256_015_6	5			Vaccines	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																								
H2256	018	1	1	01	01	H2256_018_1	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										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	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										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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											57.05	23	23	23				60.56	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											55.15	50	50	50				49.39	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	018	1	1	01	01	H2256_018_1	5			Vaccines	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																								
H2256	018	7	1	01	01	H2256_018_7	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										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	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										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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											57.05	23	23	23				60.56	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											55.15	50	50	50				49.39	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	018	7	1	01	01	H2256_018_7	5			Vaccines	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																								
H2256	018	8	1	01	01	H2256_018_8	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										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	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										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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											57.05	23	23	23				60.56	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											55.15	50	50	50				49.39	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	018	8	1	01	01	H2256_018_8	5			Vaccines	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																								
H2256	026	1	1	01	01	H2256_026_1	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										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	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										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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											50.29	23	23	23				56.47	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											51.19	50	50	50				41.57	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	026	1	1	01	01	H2256_026_1	5			Vaccines	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																								
H2256	026	2	1	01	01	H2256_026_2	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										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	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										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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											50.29	23	23	23				56.47	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											51.19	50	50	50				41.57	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	026	2	1	01	01	H2256_026_2	5			Vaccines	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																								
H2256	026	3	1	01	01	H2256_026_3	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										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	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										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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											50.29	23	23	23				56.47	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											51.19	50	50	50				41.57	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	026	3	1	01	01	H2256_026_3	5			Vaccines	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																								
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										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								20.00	40.00	60.00					6.00	12.00	18.00					6.00	12.00	12.00																20.00				6.00			0.67	0.20	0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	6.00	12.00	18.00	6.00	12.00	12.00				20.00		6.00
H2256	028	0	1	01	01	H2256_028_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											48.65	23	23	23				57.11	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											49.50	50	50	50				43.60	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																								
H2256	028	0	1	01	01	H2256_028_0	5			Vaccines	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																								
H2256	033	0	1	01	01	H2256_033_0	5			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										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	5			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										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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				58.31	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				46.13	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	033	0	1	01	01	H2256_033_0	5			Vaccines	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																								
H2256	034	0	1	01	01	H2256_034_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										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	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										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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											52.49	23	23	23				60.70	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											49.16	50	50	50				44.42	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	034	0	1	01	01	H2256_034_0	5			Vaccines	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																								
H2256	036	0	1	01	01	H2256_036_0	4			Preferred Generic	4	01	3	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					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, Vaccines										6.00	12.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00				6.00		0.00
H2256	036	0	1	01	01	H2256_036_0	4			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								11.00	22.00	33.00					0.00	0.00	0.00					0.00	0.00	0.00																11.00				0.00			0.37	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										11.00	22.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00				11.00		0.00
H2256	036	0	1	01	01	H2256_036_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											51.81	23	23	23				59.44	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											37.68	50	50	50				43.50	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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, Vaccines																								
H2256	036	0	1	01	01	H2256_036_0	4			Vaccines	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																								
H2256	046	0	1	01	01	H2256_046_0	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										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	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					6.00	12.00	12.00																20.00				6.00			0.67	0.20	0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	6.00	12.00	18.00	6.00	12.00	12.00				20.00		6.00
H2256	046	0	1	01	01	H2256_046_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											61.80	23	23	23				64.66	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											50.74	50	50	50				44.68	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H2256	046	0	1	01	01	H2256_046_0	6			Vaccines	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																								
H2261	005	0	1	01	01	H2261_005_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	18.00					0.00	0.00	0.00					0.00	0.00	0.00																6.00				6.00			0.20	0.00	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	0.00	0.00	0.00				6.00		6.00
H2261	005	0	1	01	01	H2261_005_0	5			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					5.00	10.00	10.00																10.00				10.00			0.33	0.17	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	5.00	10.00	10.00				10.00		10.00
H2261	005	0	1	01	01	H2261_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					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
H2261	005	0	1	01	01	H2261_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					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
H2261	005	0	1	01	01	H2261_005_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
H2261	022	1	1	01	01	H2261_022_1	4			Preferred Generic	4	11	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				8.00			0.27	0.00	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	0.00	0.00	0.00				8.00		8.00
H2261	022	1	1	01	01	H2261_022_1	4			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					6.00	12.00	18.00					6.00	12.00	12.00																12.00				12.00			0.40	0.20	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	6.00	12.00	12.00				12.00		12.00
H2261	022	1	1	01	01	H2261_022_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					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
H2261	022	1	1	01	01	H2261_022_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					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
H2261	022	1	1	01	01	H2261_022_1	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
H2261	022	2	1	01	01	H2261_022_2	4			Preferred Generic	4	11	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				8.00			0.27	0.00	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	0.00	0.00	0.00				8.00		8.00
H2261	022	2	1	01	01	H2261_022_2	4			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					6.00	12.00	18.00					6.00	12.00	12.00																12.00				12.00			0.40	0.20	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	6.00	12.00	12.00				12.00		12.00
H2261	022	2	1	01	01	H2261_022_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	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
H2261	022	2	1	01	01	H2261_022_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	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
H2261	022	2	1	01	01	H2261_022_2	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
H2261	023	1	1	02	01	H2261_023_1	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	18.00					0.00	0.00	0.00					0.00	0.00	0.00																6.00				6.00			0.20	0.00	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	0.00	0.00	0.00				6.00		6.00
H2261	023	1	1	02	01	H2261_023_1	5			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					5.00	10.00	10.00																10.00				10.00			0.33	0.17	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	5.00	10.00	10.00				10.00		10.00
H2261	023	1	1	02	01	H2261_023_1	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					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
H2261	023	1	1	02	01	H2261_023_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								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
H2261	023	1	1	02	01	H2261_023_1	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
H2261	023	2	1	02	01	H2261_023_2	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	18.00					0.00	0.00	0.00					0.00	0.00	0.00																6.00				6.00			0.20	0.00	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	0.00	0.00	0.00				6.00		6.00
H2261	023	2	1	02	01	H2261_023_2	5			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					5.00	10.00	10.00																10.00				10.00			0.33	0.17	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	5.00	10.00	10.00				10.00		10.00
H2261	023	2	1	02	01	H2261_023_2	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					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
H2261	023	2	1	02	01	H2261_023_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								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
H2261	023	2	1	02	01	H2261_023_2	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
H2261	024	0	1	02	01	H2261_024_0	4			Preferred Generic	4	11	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				8.00			0.27	0.00	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	0.00	0.00	0.00				8.00		8.00
H2261	024	0	1	02	01	H2261_024_0	4			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					2.00	4.00	6.00					2.00	4.00	4.00																12.00				12.00			0.40	0.07	0.07			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	2.00	4.00	4.00				12.00		12.00
H2261	024	0	1	02	01	H2261_024_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											75.72	20	20	20				80.26	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	70.00				35.00		35.00
H2261	024	0	1	02	01	H2261_024_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											83.59	40	40	40				41.09	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	70.00				35.00		35.00
H2261	024	0	1	02	01	H2261_024_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
H2293	001	0	1	04	01	H2293_001_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	001	0	1	04	01	H2293_001_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	001	0	1	04	01	H2293_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											79.00	24	24	24				102.53	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
H2293	001	0	1	04	01	H2293_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											46.53	25	25	25				42.68	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
H2293	001	0	1	04	01	H2293_001_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											832.40	25						795.40	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
H2293	010	0	1	04	01	H2293_010_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	010	0	1	04	01	H2293_010_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	010	0	1	04	01	H2293_010_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.56	22	22	22				47.64	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.64	25	25	25				51.57	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
H2293	010	0	1	04	01	H2293_010_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											345.92	25						319.07	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
H2293	011	0	1	04	01	H2293_011_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	011	0	1	04	01	H2293_011_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	011	0	1	04	01	H2293_011_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.86	24	24	24				107.64	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
H2293	011	0	1	04	01	H2293_011_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.25	25	25	25				42.82	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
H2293	011	0	1	04	01	H2293_011_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											770.04	25						761.83	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
H2293	014	0	1	04	01	H2293_014_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	014	0	1	04	01	H2293_014_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	014	0	1	04	01	H2293_014_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.53	24	24	24				106.34	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
H2293	014	0	1	04	01	H2293_014_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.63	25	25	25				29.45	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
H2293	014	0	1	04	01	H2293_014_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											870.06	25						766.53	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
H2293	016	0	1	04	01	H2293_016_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	016	0	1	04	01	H2293_016_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	016	0	1	04	01	H2293_016_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.88	24	24	24				117.88	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
H2293	016	0	1	04	01	H2293_016_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.93	25	25	25				35.53	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
H2293	016	0	1	04	01	H2293_016_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											815.80	25						862.49	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
H2293	017	0	1	04	01	H2293_017_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	017	0	1	04	01	H2293_017_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	017	0	1	04	01	H2293_017_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											101.31	24	24	24				124.25	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
H2293	017	0	1	04	01	H2293_017_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.27	25	25	25				33.13	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
H2293	017	0	1	04	01	H2293_017_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1058.69	25						669.48	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
H2293	019	0	1	04	01	H2293_019_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	019	0	1	04	01	H2293_019_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	019	0	1	04	01	H2293_019_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.03	24	24	24				114.68	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
H2293	019	0	1	04	01	H2293_019_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.38	25	25	25				34.75	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
H2293	019	0	1	04	01	H2293_019_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											903.69	25						819.41	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
H2293	023	0	1	04	01	H2293_023_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	023	0	1	04	01	H2293_023_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2293	023	0	1	04	01	H2293_023_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					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
H2293	023	0	1	04	01	H2293_023_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											830.76	25						803.26	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
H2293	025	0	1	04	01	H2293_025_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	025	0	1	04	01	H2293_025_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	025	0	1	04	01	H2293_025_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.85	24	24	24				106.75	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
H2293	025	0	1	04	01	H2293_025_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.82	25	25	25				35.31	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	105.00	35.00	70.00	105.00	35.00		35.00
H2293	025	0	1	04	01	H2293_025_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											844.20	25						780.81	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
H2293	026	0	1	04	01	H2293_026_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	026	0	1	04	01	H2293_026_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	026	0	1	04	01	H2293_026_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.29	22	22	22				40.79	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	026	0	1	04	01	H2293_026_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.89	25	25	25				43.98	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
H2293	026	0	1	04	01	H2293_026_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											351.27	25						309.66	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
H2293	028	0	1	04	01	H2293_028_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	028	0	1	04	01	H2293_028_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	028	0	1	04	01	H2293_028_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.04	22	22	22				42.52	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	028	0	1	04	01	H2293_028_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.24	25	25	25				46.04	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
H2293	028	0	1	04	01	H2293_028_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											367.85	25						326.73	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
H2293	029	0	1	04	01	H2293_029_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	029	0	1	04	01	H2293_029_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	029	0	1	04	01	H2293_029_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.03	24	24	24				111.54	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
H2293	029	0	1	04	01	H2293_029_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.35	25	25	25				37.39	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
H2293	029	0	1	04	01	H2293_029_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											864.01	25						809.05	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
H2293	031	0	1	04	01	H2293_031_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	031	0	1	04	01	H2293_031_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	031	0	1	04	01	H2293_031_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.89	22	22	22				42.44	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	031	0	1	04	01	H2293_031_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.34	25	25	25				46.23	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
H2293	031	0	1	04	01	H2293_031_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											367.86	25						327.39	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
H2293	033	0	1	04	01	H2293_033_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	033	0	1	04	01	H2293_033_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2293	033	0	1	04	01	H2293_033_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.58	24	24	24				106.23	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
H2293	033	0	1	04	01	H2293_033_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.51	25	25	25				42.76	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
H2293	033	0	1	04	01	H2293_033_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											767.84	25						755.68	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
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																								
H2320	022	1	1	02	01	H2320_022_1	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											99.61	25	25	25				100.78	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
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											17.61	50	50	50				15.23	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																								
H2320	022	2	1	02	01	H2320_022_2	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											99.61	25	25	25				100.78	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
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											17.61	50	50	50				15.23	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	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					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	5			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																								
H2320	022	3	1	02	01	H2320_022_3	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											99.61	25	25	25				100.78	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
H2320	022	3	1	02	01	H2320_022_3	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											17.61	50	50	50				15.23	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	5			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	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					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	5			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																								
H2320	022	4	1	02	01	H2320_022_4	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											99.61	25	25	25				100.78	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
H2320	022	4	1	02	01	H2320_022_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											17.61	50	50	50				15.23	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	5			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																								
H2320	022	5	1	02	01	H2320_022_5	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											99.61	25	25	25				100.78	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
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											17.61	50	50	50				15.23	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	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					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	5			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																								
H2320	028	1	1	02	01	H2320_028_1	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											93.95	25	25	25				95.26	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
H2320	028	1	1	02	01	H2320_028_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											16.54	45	45	45				17.26	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	5			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	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					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	5			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																								
H2320	028	2	1	02	01	H2320_028_2	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											93.95	25	25	25				95.26	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
H2320	028	2	1	02	01	H2320_028_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											16.54	45	45	45				17.26	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	5			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	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					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	5			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																								
H2320	028	3	1	02	01	H2320_028_3	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											93.95	25	25	25				95.26	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
H2320	028	3	1	02	01	H2320_028_3	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											16.54	45	45	45				17.26	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	5			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	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					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	5			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																								
H2320	028	4	1	02	01	H2320_028_4	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											93.95	25	25	25				95.26	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
H2320	028	4	1	02	01	H2320_028_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											16.54	45	45	45				17.26	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	5			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	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					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	5			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																								
H2320	028	5	1	02	01	H2320_028_5	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											93.95	25	25	25				95.26	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
H2320	028	5	1	02	01	H2320_028_5	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											16.54	45	45	45				17.26	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	5			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																								
H2320	029	1	1	02	01	H2320_029_1	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.55	25	25	25				95.56	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
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											17.72	50	50	50				18.09	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	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	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																								
H2320	029	2	1	02	01	H2320_029_2	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.55	25	25	25				95.56	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
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											17.72	50	50	50				18.09	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	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	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																								
H2320	029	3	1	02	01	H2320_029_3	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.55	25	25	25				95.56	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
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											17.72	50	50	50				18.09	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	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	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																								
H2320	029	4	1	02	01	H2320_029_4	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.55	25	25	25				95.56	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
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											17.72	50	50	50				18.09	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	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	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																								
H2320	029	5	1	02	01	H2320_029_5	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.55	25	25	25				95.56	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
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											17.72	50	50	50				18.09	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	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	031	0	1	02	01	H2320_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								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	031	0	1	02	01	H2320_031_0	5			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																								
H2320	031	0	1	02	01	H2320_031_0	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.59	25	25	25				101.47	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
H2320	031	0	1	02	01	H2320_031_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											20.56	45	45	45				13.54	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
H2320	031	0	1	02	01	H2320_031_0	5			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	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.30	0.00		0.30	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2322	008	0	1	04	01	H2322_008_0	8			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										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
H2322	008	0	1	04	01	H2322_008_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											110.56	22	22	22				103.52	20	20	20										22	22	22				20	20	20			22			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
H2322	008	0	1	04	01	H2322_008_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.37	50	50	50				47.32	48	48	48										50	50	50				48	48	48			50			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
H2322	008	0	1	04	01	H2322_008_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										35.00			35.00			35.00			35.00			35.00		35.00
H2322	011	0	1	04	01	H2322_011_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.30	0.00		0.30	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2322	011	0	1	04	01	H2322_011_0	7			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										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
H2322	011	0	1	04	01	H2322_011_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											83.30	17	17	17				76.52	15	15	15										17	17	17				15	15	15			17			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2322	011	0	1	04	01	H2322_011_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											96.60	50	50	50				85.42	48	48	48										50	50	50				48	48	48			50			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
H2322	011	0	1	04	01	H2322_011_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										35.00			35.00			35.00			35.00			35.00		35.00
H2322	016	0	1	04	01	H2322_016_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.30	0.00		0.30	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2322	016	0	1	04	01	H2322_016_0	8			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										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
H2322	016	0	1	04	01	H2322_016_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											99.89	20	20	20				93.87	18	18	18										20	20	20				18	18	18			20			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
H2322	016	0	1	04	01	H2322_016_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											94.42	50	50	50				84.62	48	48	48										50	50	50				48	48	48			50			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
H2322	016	0	1	04	01	H2322_016_0	8			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										35.00			35.00			35.00			35.00			35.00		35.00
H2322	017	0	1	04	01	H2322_017_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.30	0.00		0.30	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2322	017	0	1	04	01	H2322_017_0	7			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					10.00	20.00	30.00											16.00	32.00	48.00				10.00	20.00	0.00				16.00				10.00			0.53	0.33		0.53	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	10.00	20.00	30.00	16.00	32.00	48.00	10.00	20.00	0.00	16.00		10.00
H2322	017	0	1	04	01	H2322_017_0	7			Preferred Brand	2	10	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											110.50	23	23	23				100.79	21	21	21										23	23	23				21	21	21			23			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
H2322	017	0	1	04	01	H2322_017_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											87.28	50	50	50				85.80	48	48	48										50	50	50				48	48	48			50			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
H2322	017	0	1	04	01	H2322_017_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
H2354	015	0	1	01	01	H2354_015_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2354	015	0	1	01	01	H2354_015_0	8			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										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
H2354	015	0	1	01	01	H2354_015_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											85.60	17	17	17				76.73	15	15	15										17	17	17				15	15	15			17			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2354	015	0	1	01	01	H2354_015_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											85.21	50	50	50				81.22	48	48	48										50	50	50				48	48	48			50			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
H2354	015	0	1	01	01	H2354_015_0	8			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
H2354	018	0	1	01	01	H2354_018_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2354	018	0	1	01	01	H2354_018_0	7			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										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
H2354	018	0	1	01	01	H2354_018_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											110.85	22	22	22				103.32	20	20	20										22	22	22				20	20	20			22			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
H2354	018	0	1	01	01	H2354_018_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.53	50	50	50				40.34	48	48	48										50	50	50				48	48	48			50			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
H2354	018	0	1	01	01	H2354_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										35.00			35.00			35.00			35.00			35.00		35.00
H2354	021	0	1	02	01	H2354_021_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2354	021	0	1	02	01	H2354_021_0	8			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										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
H2354	021	0	1	02	01	H2354_021_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											110.64	22	22	22				101.64	20	20	20										22	22	22				20	20	20			22			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
H2354	021	0	1	02	01	H2354_021_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.85	50	50	50				41.84	48	48	48										50	50	50				48	48	48			50			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
H2354	021	0	1	02	01	H2354_021_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										35.00			35.00			35.00			35.00			35.00		35.00
H2354	028	0	1	01	01	H2354_028_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2354	028	0	1	01	01	H2354_028_0	9			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										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
H2354	028	0	1	01	01	H2354_028_0	9			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											85.47	17	17	17				79.48	15	15	15										17	17	17				15	15	15			17			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2354	028	0	1	01	01	H2354_028_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											96.47	50	50	50				81.93	48	48	48										50	50	50				48	48	48			50			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
H2354	028	0	1	01	01	H2354_028_0	9			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
H2354	029	0	1	01	01	H2354_029_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	2	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				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2354	029	0	1	01	01	H2354_029_0	7			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										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
H2354	029	0	1	01	01	H2354_029_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											83.97	17	17	17				78.90	15	15	15										17	17	17				15	15	15			17			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2354	029	0	1	01	01	H2354_029_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											80.17	50	50	50				77.54	48	48	48										50	50	50				48	48	48			50			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
H2354	029	0	1	01	01	H2354_029_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										35.00			35.00			35.00			35.00			35.00		35.00
H2406	008	0	1	04	01	H2406_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																								
H2406	008	0	1	04	01	H2406_008_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	008	0	1	04	01	H2406_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
H2406	008	0	1	04	01	H2406_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	008	0	1	04	01	H2406_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H2406	009	0	1	04	01	H2406_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																								
H2406	009	0	1	04	01	H2406_009_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	009	0	1	04	01	H2406_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
H2406	009	0	1	04	01	H2406_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	009	0	1	04	01	H2406_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				211.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010	0	1	04	01	H2406_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				193.00	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
H2406	011	0	1	04	01	H2406_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																								
H2406	011	0	1	04	01	H2406_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																								
H2406	011	0	1	04	01	H2406_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
H2406	011	0	1	04	01	H2406_011_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	011	0	1	04	01	H2406_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				192.00	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
H2406	013	0	1	04	01	H2406_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																								
H2406	013	0	1	04	01	H2406_013_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																								
H2406	013	0	1	04	01	H2406_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
H2406	013	0	1	04	01	H2406_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	013	0	1	04	01	H2406_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H2406	014	0	1	04	01	H2406_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																								
H2406	014	0	1	04	01	H2406_014_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	014	0	1	04	01	H2406_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
H2406	014	0	1	04	01	H2406_014_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	014	0	1	04	01	H2406_014_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				207.00	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
H2406	015	0	1	04	01	H2406_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																								
H2406	015	0	1	04	01	H2406_015_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	015	0	1	04	01	H2406_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
H2406	015	0	1	04	01	H2406_015_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	015	0	1	04	01	H2406_015_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H2406	016	0	1	04	01	H2406_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																								
H2406	016	0	1	04	01	H2406_016_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	016	0	1	04	01	H2406_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
H2406	016	0	1	04	01	H2406_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	016	0	1	04	01	H2406_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
H2406	017	0	1	04	01	H2406_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																								
H2406	017	0	1	04	01	H2406_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																								
H2406	017	0	1	04	01	H2406_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
H2406	017	0	1	04	01	H2406_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	017	0	1	04	01	H2406_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				190.00	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
H2406	018	0	1	04	01	H2406_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																								
H2406	018	0	1	04	01	H2406_018_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	018	0	1	04	01	H2406_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
H2406	018	0	1	04	01	H2406_018_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	018	0	1	04	01	H2406_018_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
H2406	019	0	1	04	01	H2406_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																								
H2406	019	0	1	04	01	H2406_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																								
H2406	019	0	1	04	01	H2406_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
H2406	019	0	1	04	01	H2406_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	019	0	1	04	01	H2406_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				213.00	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
H2406	034	0	1	04	01	H2406_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																								
H2406	034	0	1	04	01	H2406_034_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																								
H2406	034	0	1	04	01	H2406_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
H2406	034	0	1	04	01	H2406_034_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	034	0	1	04	01	H2406_034_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H2406	035	0	1	04	01	H2406_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																								
H2406	035	0	1	04	01	H2406_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																								
H2406	035	0	1	04	01	H2406_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
H2406	035	0	1	04	01	H2406_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	035	0	1	04	01	H2406_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H2406	036	0	1	04	01	H2406_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																								
H2406	036	0	1	04	01	H2406_036_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																								
H2406	036	0	1	04	01	H2406_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
H2406	036	0	1	04	01	H2406_036_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	036	0	1	04	01	H2406_036_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				202.00	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
H2406	037	0	1	04	01	H2406_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																								
H2406	037	0	1	04	01	H2406_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																								
H2406	037	0	1	04	01	H2406_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
H2406	037	0	1	04	01	H2406_037_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	037	0	1	04	01	H2406_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H2406	038	0	1	04	01	H2406_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																								
H2406	038	0	1	04	01	H2406_038_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																								
H2406	038	0	1	04	01	H2406_038_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	038	0	1	04	01	H2406_038_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	038	0	1	04	01	H2406_038_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H2406	039	0	1	04	01	H2406_039_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	039	0	1	04	01	H2406_039_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	039	0	1	04	01	H2406_039_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	039	0	1	04	01	H2406_039_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	039	0	1	04	01	H2406_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				225.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	040	0	1	04	01	H2406_040_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				269.00	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
H2406	042	0	1	04	01	H2406_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																								
H2406	042	0	1	04	01	H2406_042_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	042	0	1	04	01	H2406_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
H2406	042	0	1	04	01	H2406_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	042	0	1	04	01	H2406_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
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			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	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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	043	0	1	04	01	H2406_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				180.00	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
H2406	044	0	1	04	01	H2406_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																								
H2406	044	0	1	04	01	H2406_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																								
H2406	044	0	1	04	01	H2406_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
H2406	044	0	1	04	01	H2406_044_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	044	0	1	04	01	H2406_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H2406	045	0	1	04	01	H2406_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																								
H2406	045	0	1	04	01	H2406_045_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																								
H2406	045	0	1	04	01	H2406_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
H2406	045	0	1	04	01	H2406_045_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	045	0	1	04	01	H2406_045_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				153.00	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
H2406	046	0	1	04	01	H2406_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																								
H2406	046	0	1	04	01	H2406_046_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																								
H2406	046	0	1	04	01	H2406_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
H2406	046	0	1	04	01	H2406_046_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	046	0	1	04	01	H2406_046_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				146.00	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
H2406	047	0	1	04	01	H2406_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																								
H2406	047	0	1	04	01	H2406_047_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																								
H2406	047	0	1	04	01	H2406_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
H2406	047	0	1	04	01	H2406_047_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	047	0	1	04	01	H2406_047_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H2406	048	0	1	04	01	H2406_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																								
H2406	048	0	1	04	01	H2406_048_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																								
H2406	048	0	1	04	01	H2406_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
H2406	048	0	1	04	01	H2406_048_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	048	0	1	04	01	H2406_048_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
H2406	050	0	1	04	01	H2406_050_0	6		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				2	2			100				30		31				0.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2406	050	0	1	04	01	H2406_050_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																								
H2406	050	0	1	04	01	H2406_050_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				81.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H2406	050	0	1	04	01	H2406_050_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				47.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H2406	050	0	1	04	01	H2406_050_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				191.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H2406	054	0	1	04	01	H2406_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																								
H2406	054	0	1	04	01	H2406_054_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																								
H2406	054	0	1	04	01	H2406_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
H2406	054	0	1	04	01	H2406_054_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	054	0	1	04	01	H2406_054_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				223.00	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
H2406	055	0	1	04	01	H2406_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																								
H2406	055	0	1	04	01	H2406_055_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																								
H2406	055	0	1	04	01	H2406_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
H2406	055	0	1	04	01	H2406_055_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	055	0	1	04	01	H2406_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				181.00	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
H2406	056	0	1	04	01	H2406_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																								
H2406	056	0	1	04	01	H2406_056_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	056	0	1	04	01	H2406_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
H2406	056	0	1	04	01	H2406_056_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	056	0	1	04	01	H2406_056_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				150.00	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
H2406	058	0	1	04	01	H2406_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																								
H2406	058	0	1	04	01	H2406_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																								
H2406	058	0	1	04	01	H2406_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
H2406	058	0	1	04	01	H2406_058_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	058	0	1	04	01	H2406_058_0	6			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										35.00						35.00			35.00			35.00		35.00
H2406	059	0	1	04	01	H2406_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																								
H2406	059	0	1	04	01	H2406_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																								
H2406	059	0	1	04	01	H2406_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
H2406	059	0	1	04	01	H2406_059_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	059	0	1	04	01	H2406_059_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				212.00	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
H2406	060	0	1	04	01	H2406_060_0	6			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																								
H2406	060	0	1	04	01	H2406_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																								
H2406	060	0	1	04	01	H2406_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
H2406	060	0	1	04	01	H2406_060_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	060	0	1	04	01	H2406_060_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				190.00	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
H2406	061	0	1	04	01	H2406_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																								
H2406	061	0	1	04	01	H2406_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																								
H2406	061	0	1	04	01	H2406_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
H2406	061	0	1	04	01	H2406_061_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	061	0	1	04	01	H2406_061_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H2406	062	0	1	04	01	H2406_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																								
H2406	062	0	1	04	01	H2406_062_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																								
H2406	062	0	1	04	01	H2406_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
H2406	062	0	1	04	01	H2406_062_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	062	0	1	04	01	H2406_062_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				180.00	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
H2406	063	0	1	04	01	H2406_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																								
H2406	063	0	1	04	01	H2406_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																								
H2406	063	0	1	04	01	H2406_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
H2406	063	0	1	04	01	H2406_063_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	063	0	1	04	01	H2406_063_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				157.00	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
H2406	064	0	1	04	01	H2406_064_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	064	0	1	04	01	H2406_064_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	064	0	1	04	01	H2406_064_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	064	0	1	04	01	H2406_064_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	064	0	1	04	01	H2406_064_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	065	0	1	04	01	H2406_065_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				186.00	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
H2406	066	0	1	04	01	H2406_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																								
H2406	066	0	1	04	01	H2406_066_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																								
H2406	066	0	1	04	01	H2406_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
H2406	066	0	1	04	01	H2406_066_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	066	0	1	04	01	H2406_066_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
H2406	067	0	1	04	01	H2406_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																								
H2406	067	0	1	04	01	H2406_067_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	067	0	1	04	01	H2406_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
H2406	067	0	1	04	01	H2406_067_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	067	0	1	04	01	H2406_067_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H2406	068	0	1	04	01	H2406_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																								
H2406	068	0	1	04	01	H2406_068_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	068	0	1	04	01	H2406_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
H2406	068	0	1	04	01	H2406_068_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	068	0	1	04	01	H2406_068_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
H2406	069	0	1	04	01	H2406_069_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	069	0	1	04	01	H2406_069_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	069	0	1	04	01	H2406_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
H2406	069	0	1	04	01	H2406_069_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	069	0	1	04	01	H2406_069_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				160.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				168.00	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
H2406	071	0	1	04	01	H2406_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																								
H2406	071	0	1	04	01	H2406_071_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	071	0	1	04	01	H2406_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
H2406	071	0	1	04	01	H2406_071_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	071	0	1	04	01	H2406_071_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H2406	072	0	1	04	01	H2406_072_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	072	0	1	04	01	H2406_072_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																								
H2406	072	0	1	04	01	H2406_072_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	072	0	1	04	01	H2406_072_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	072	0	1	04	01	H2406_072_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				158.00	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
H2406	075	0	1	04	01	H2406_075_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	075	0	1	04	01	H2406_075_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	075	0	1	04	01	H2406_075_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	075	0	1	04	01	H2406_075_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	075	0	1	04	01	H2406_075_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				192.00	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
H2406	076	0	1	04	01	H2406_076_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	076	0	1	04	01	H2406_076_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	076	0	1	04	01	H2406_076_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	076	0	1	04	01	H2406_076_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	076	0	1	04	01	H2406_076_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H2406	078	0	1	04	01	H2406_078_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	078	0	1	04	01	H2406_078_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	078	0	1	04	01	H2406_078_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	078	0	1	04	01	H2406_078_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	078	0	1	04	01	H2406_078_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				178.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				243.00	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
H2406	082	0	1	04	01	H2406_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																								
H2406	082	0	1	04	01	H2406_082_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	082	0	1	04	01	H2406_082_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	082	0	1	04	01	H2406_082_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	082	0	1	04	01	H2406_082_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				225.00	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
H2406	083	0	1	04	01	H2406_083_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	083	0	1	04	01	H2406_083_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	20.00		60.00																											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	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	083	0	1	04	01	H2406_083_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	083	0	1	04	01	H2406_083_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H2406	084	0	1	04	01	H2406_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																								
H2406	084	0	1	04	01	H2406_084_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	20.00		60.00																											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	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	084	0	1	04	01	H2406_084_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	084	0	1	04	01	H2406_084_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				164.00	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
H2406	086	0	1	04	01	H2406_086_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	086	0	1	04	01	H2406_086_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	086	0	1	04	01	H2406_086_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	086	0	1	04	01	H2406_086_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	086	0	1	04	01	H2406_086_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				199.00	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
H2406	087	0	1	04	01	H2406_087_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	087	0	1	04	01	H2406_087_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	087	0	1	04	01	H2406_087_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	087	0	1	04	01	H2406_087_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	087	0	1	04	01	H2406_087_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H2406	088	0	1	04	01	H2406_088_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	088	0	1	04	01	H2406_088_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	088	0	1	04	01	H2406_088_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	088	0	1	04	01	H2406_088_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	088	0	1	04	01	H2406_088_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H2406	089	0	1	04	01	H2406_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																								
H2406	089	0	1	04	01	H2406_089_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																								
H2406	089	0	1	04	01	H2406_089_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	089	0	1	04	01	H2406_089_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	089	0	1	04	01	H2406_089_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				213.00	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
H2406	090	0	1	04	01	H2406_090_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	090	0	1	04	01	H2406_090_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	090	0	1	04	01	H2406_090_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	090	0	1	04	01	H2406_090_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	090	0	1	04	01	H2406_090_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				216.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				169.00	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
H2406	093	0	1	04	01	H2406_093_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	093	0	1	04	01	H2406_093_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	093	0	1	04	01	H2406_093_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	093	0	1	04	01	H2406_093_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	093	0	1	04	01	H2406_093_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	095	0	1	04	01	H2406_095_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				182.00	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
H2406	096	0	1	04	01	H2406_096_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	096	0	1	04	01	H2406_096_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																								
H2406	096	0	1	04	01	H2406_096_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	096	0	1	04	01	H2406_096_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	096	0	1	04	01	H2406_096_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				205.00	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
H2406	097	0	1	04	01	H2406_097_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	097	0	1	04	01	H2406_097_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	097	0	1	04	01	H2406_097_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	097	0	1	04	01	H2406_097_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	097	0	1	04	01	H2406_097_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				239.00	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
H2406	098	0	1	04	01	H2406_098_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	098	0	1	04	01	H2406_098_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	098	0	1	04	01	H2406_098_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	098	0	1	04	01	H2406_098_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	098	0	1	04	01	H2406_098_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H2406	100	0	1	04	01	H2406_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																								
H2406	100	0	1	04	01	H2406_100_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																								
H2406	100	0	1	04	01	H2406_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
H2406	100	0	1	04	01	H2406_100_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	100	0	1	04	01	H2406_100_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H2406	101	0	1	04	01	H2406_101_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	101	0	1	04	01	H2406_101_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	101	0	1	04	01	H2406_101_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	101	0	1	04	01	H2406_101_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	101	0	1	04	01	H2406_101_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				156.00	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
H2406	102	0	1	04	01	H2406_102_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	102	0	1	04	01	H2406_102_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	102	0	1	04	01	H2406_102_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	102	0	1	04	01	H2406_102_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	102	0	1	04	01	H2406_102_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				203.00	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
H2406	103	0	1	04	01	H2406_103_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	103	0	1	04	01	H2406_103_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	103	0	1	04	01	H2406_103_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	103	0	1	04	01	H2406_103_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	103	0	1	04	01	H2406_103_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				170.00	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
H2406	104	0	1	04	01	H2406_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																								
H2406	104	0	1	04	01	H2406_104_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	104	0	1	04	01	H2406_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
H2406	104	0	1	04	01	H2406_104_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	104	0	1	04	01	H2406_104_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
H2406	105	0	1	04	01	H2406_105_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	105	0	1	04	01	H2406_105_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	105	0	1	04	01	H2406_105_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	105	0	1	04	01	H2406_105_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	105	0	1	04	01	H2406_105_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
H2406	106	0	1	04	01	H2406_106_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	106	0	1	04	01	H2406_106_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	106	0	1	04	01	H2406_106_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	106	0	1	04	01	H2406_106_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	106	0	1	04	01	H2406_106_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H2406	110	0	1	04	01	H2406_110_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	110	0	1	04	01	H2406_110_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	110	0	1	04	01	H2406_110_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	110	0	1	04	01	H2406_110_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	110	0	1	04	01	H2406_110_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				157.00	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
H2406	111	0	1	04	01	H2406_111_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	111	0	1	04	01	H2406_111_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	111	0	1	04	01	H2406_111_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	111	0	1	04	01	H2406_111_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	111	0	1	04	01	H2406_111_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				153.00	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
H2406	112	0	1	04	01	H2406_112_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	112	0	1	04	01	H2406_112_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	112	0	1	04	01	H2406_112_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	112	0	1	04	01	H2406_112_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	112	0	1	04	01	H2406_112_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H2406	113	0	1	04	01	H2406_113_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	113	0	1	04	01	H2406_113_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	113	0	1	04	01	H2406_113_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	113	0	1	04	01	H2406_113_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	113	0	1	04	01	H2406_113_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H2406	115	0	1	04	01	H2406_115_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	115	0	1	04	01	H2406_115_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																								
H2406	115	0	1	04	01	H2406_115_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	115	0	1	04	01	H2406_115_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	115	0	1	04	01	H2406_115_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				160.00	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
H2406	119	0	1	04	01	H2406_119_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	119	0	1	04	01	H2406_119_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	119	0	1	04	01	H2406_119_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	119	0	1	04	01	H2406_119_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	119	0	1	04	01	H2406_119_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				239.00	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
H2406	121	0	1	04	01	H2406_121_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	121	0	1	04	01	H2406_121_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	121	0	1	04	01	H2406_121_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	121	0	1	04	01	H2406_121_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	121	0	1	04	01	H2406_121_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				237.00	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
H2406	122	0	1	04	01	H2406_122_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	122	0	1	04	01	H2406_122_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	122	0	1	04	01	H2406_122_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	122	0	1	04	01	H2406_122_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	122	0	1	04	01	H2406_122_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				180.00	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
H2406	125	0	1	04	01	H2406_125_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	125	0	1	04	01	H2406_125_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	125	0	1	04	01	H2406_125_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	125	0	1	04	01	H2406_125_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	125	0	1	04	01	H2406_125_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				162.00	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
H2406	129	0	1	04	01	H2406_129_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	129	0	1	04	01	H2406_129_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																								
H2406	129	0	1	04	01	H2406_129_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	129	0	1	04	01	H2406_129_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	129	0	1	04	01	H2406_129_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				133.00	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
H2406	135	0	1	04	01	H2406_135_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	135	0	1	04	01	H2406_135_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	135	0	1	04	01	H2406_135_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	135	0	1	04	01	H2406_135_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2406	135	0	1	04	01	H2406_135_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				215.00	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
H2441	001	0	1	04	01	H2441_001_0	9		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, Select Care Drugs																								
H2441	001	0	1	04	01	H2441_001_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.92	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2441	001	0	1	04	01	H2441_001_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				67.11	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
H2441	001	0	1	04	01	H2441_001_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				38.85	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
H2441	001	0	1	04	01	H2441_001_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2441	001	0	1	04	01	H2441_001_0	9		N	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																								
H2450	001	0	1	18	06	H2450_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								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	12.50				10.00				5.00			0.33	0.17		0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	001	0	1	18	06	H2450_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					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	37.50				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	001	0	1	18	06	H2450_001_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.90	18	18	18				58.33	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	87.50	35.00		35.00
H2450	001	0	1	18	06	H2450_001_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.28	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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H2450	001	0	1	18	06	H2450_001_0	4			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																								
H2450	002	0	1	18	06	H2450_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								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	5.00				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	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	24.00											20.00	40.00	60.00				8.00	16.00	20.00				20.00				8.00			0.67	0.27		0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	002	0	1	18	06	H2450_002_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.68	21	21	21				67.81	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	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H2450	002	0	1	18	06	H2450_002_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											63.54	50	50	50				60.85	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	87.50	35.00		35.00
H2450	002	0	1	18	06	H2450_002_0	4			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																								
H2450	007	0	1	18	06	H2450_007_0	7			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					8.00	16.00	24.00											15.00	30.00	45.00				8.00	16.00	20.00				15.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	007	0	1	18	06	H2450_007_0	7			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					14.00	28.00	42.00											20.00	40.00	60.00				14.00	28.00	35.00				20.00				14.00			0.67	0.47		0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	007	0	1	18	06	H2450_007_0	7			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											77.99	20	20	20				76.84	20	20	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	70.00	87.50	35.00		35.00
H2450	007	0	1	18	06	H2450_007_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											83.05	50	50	50				84.82	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	87.50	35.00		35.00
H2450	007	0	1	18	06	H2450_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																								
H2450	016	0	1	18	06	H2450_016_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					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	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					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	25.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	016	0	1	18	06	H2450_016_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											60.36	18	18	18				62.60	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	87.50	35.00		35.00
H2450	016	0	1	18	06	H2450_016_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.67	50	50	50				76.10	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	87.50	35.00		35.00
H2450	016	0	1	18	06	H2450_016_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																								
H2450	035	0	1	18	06	H2450_035_0	4			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	5.00																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	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	30.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	035	0	1	18	06	H2450_035_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				58.72	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	87.50				35.00		35.00
H2450	035	0	1	18	06	H2450_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				74.14	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	87.50				35.00		35.00
H2450	035	0	1	18	06	H2450_035_0	4			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	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	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	037	0	1	18	06	H2450_037_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	30.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	037	0	1	18	06	H2450_037_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				31.39	11	11	11																		11	11	11															11			11								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
H2450	037	0	1	18	06	H2450_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				63.73	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
H2450	037	0	1	18	06	H2450_037_0	4			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	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					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	5.00				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	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					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	25.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	039	0	1	18	06	H2450_039_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											56.13	17	17	17				59.46	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	87.50	35.00		35.00
H2450	039	0	1	18	06	H2450_039_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.54	50	50	50				65.99	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	87.50	35.00		35.00
H2450	039	0	1	18	06	H2450_039_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																								
H2450	041	0	1	18	06	H2450_041_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					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	5.00				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	041	0	1	18	06	H2450_041_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					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	30.00				20.00				12.00			0.67	0.40		0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	041	0	1	18	06	H2450_041_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.83	16	16	16				49.90	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	87.50	35.00		35.00
H2450	041	0	1	18	06	H2450_041_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.29	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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H2450	041	0	1	18	06	H2450_041_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																								
H2450	049	0	1	18	06	H2450_049_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	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2450	049	0	1	18	06	H2450_049_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																			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																								
H2450	049	0	1	18	06	H2450_049_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				48.52	15	15	15																		15	15	15															15			15								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
H2450	049	0	1	18	06	H2450_049_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				78.66	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	87.50				35.00		35.00
H2450	049	0	1	18	06	H2450_049_0	4			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																								
H2459	021	1	1	02	01	H2459_021_1	12			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	12			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	12			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	12			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										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	12			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2000.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	021	2	1	02	01	H2459_021_2	12			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	12			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	12			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	12			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										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	12			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2000.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	021	3	1	02	01	H2459_021_3	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																								
H2459	021	3	1	02	01	H2459_021_3	13			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	13			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	13			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										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	13			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2000.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	023	1	1	02	01	H2459_023_1	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																								
H2459	023	1	1	02	01	H2459_023_1	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																								
H2459	023	1	1	02	01	H2459_023_1	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
H2459	023	1	1	02	01	H2459_023_1	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										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	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1705.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	023	2	1	02	01	H2459_023_2	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																								
H2459	023	2	1	02	01	H2459_023_2	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																								
H2459	023	2	1	02	01	H2459_023_2	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
H2459	023	2	1	02	01	H2459_023_2	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										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	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1705.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	024	0	1	02	01	H2459_024_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																								
H2459	024	0	1	02	01	H2459_024_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																								
H2459	024	0	1	02	01	H2459_024_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
H2459	024	0	1	02	01	H2459_024_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										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	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1520.00	27																				27																		27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	026	1	1	02	01	H2459_026_1	11			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	11			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	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	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	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	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
H2459	026	1	1	02	01	H2459_026_1	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1765.00	30																				30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	026	3	1	02	01	H2459_026_3	11			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	11			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	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	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	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	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
H2459	026	3	1	02	01	H2459_026_3	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1765.00	30																				30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	026	4	1	02	01	H2459_026_4	11			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	11			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	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	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	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	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
H2459	026	4	1	02	01	H2459_026_4	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1765.00	30																				30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	029	0	1	02	01	H2459_029_0	11			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	11			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	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	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	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	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
H2459	029	0	1	02	01	H2459_029_0	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1705.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2459	031	0	1	01	01	H2459_031_0	8			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	8			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	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	031	0	1	01	01	H2459_031_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										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	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1875.00	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										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			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1983.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2461	008	0	1	18	06	H2461_008_0	5			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	5			Generic	2	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	5.00	10.00	10.00																									10.00	20.00	20.00				5.00	10.00	10.00				5.00				5.00		0.16				0.32	0.16	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										5.00	10.00	10.00				10.00	20.00	20.00	5.00	10.00	10.00	5.00		5.00
H2461	008	0	1	18	06	H2461_008_0	5			Preferred Brand	2	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				77.15	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	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	5			Non-Preferred Drug	2	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				68.96	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	5			Specialty Tier	2	11	1	1	5	1	010		01		010	1	31											31			31		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2461	009	0	1	18	06	H2461_009_0	5			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	5			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
H2461	009	0	1	18	06	H2461_009_0	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				78.65	24	24	24																								25	25	25				24	24	24			24			24								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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				78.97	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	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2461	010	0	1	18	06	H2461_010_0	5			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	5			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	2.00	4.00	4.00																									7.00	14.00	14.00				2.00	4.00	4.00				2.00				2.00		0.06				0.23	0.06	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2.00	4.00	4.00				7.00	14.00	14.00	2.00	4.00	4.00	2.00		2.00
H2461	010	0	1	18	06	H2461_010_0	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				80.26	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	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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				60.13	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	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2463	001	0	1	01	01	H2463_001_0	4			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
H2463	001	0	1	01	01	H2463_001_0	4			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
H2463	001	0	1	01	01	H2463_001_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		70.00	35.00		35.00
H2463	001	0	1	01	01	H2463_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H2463	001	0	1	01	01	H2463_001_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
H2486	003	0	1	01	01	H2486_003_0	3			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	3			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	003	0	1	01	01	H2486_003_0	3			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		95.00	35.00		35.00
H2486	003	0	1	01	01	H2486_003_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	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
H2486	003	0	1	01	01	H2486_003_0	3			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	005	0	1	01	01	H2486_005_0	3			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	3			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	005	0	1	01	01	H2486_005_0	3			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		95.00	35.00		35.00
H2486	005	0	1	01	01	H2486_005_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H2486	005	0	1	01	01	H2486_005_0	3			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	006	0	1	01	01	H2486_006_0	3			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	006	0	1	01	01	H2486_006_0	3			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	006	0	1	01	01	H2486_006_0	3			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		95.00	35.00		35.00
H2486	006	0	1	01	01	H2486_006_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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
H2486	006	0	1	01	01	H2486_006_0	3			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	007	0	1	01	01	H2486_007_0	3			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	3			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	007	0	1	01	01	H2486_007_0	3			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		95.00	35.00		35.00
H2486	007	0	1	01	01	H2486_007_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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
H2486	007	0	1	01	01	H2486_007_0	3			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
H2491	009	0	1	01	01	H2491_009_0	4			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																								
H2491	009	0	1	01	01	H2491_009_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	20.00	30.00				0.00	0.00	0.00				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	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.69	25	25	25				153.69	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
H2491	009	0	1	01	01	H2491_009_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.24	41	41	41				99.24	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
H2491	009	0	1	01	01	H2491_009_0	4			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																								
H2491	009	0	1	01	01	H2491_009_0	4			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	02	01	H2491_010_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2491	010	0	1	02	01	H2491_010_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2491	010	0	1	02	01	H2491_010_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											150.87	24	24	24				144.58	23	23	23										24	24	24				23	23	23			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
H2491	010	0	1	02	01	H2491_010_0	5			Non-Preferred Drug	3	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	200.00				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
H2491	010	0	1	02	01	H2491_010_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																								
H2491	010	0	1	02	01	H2491_010_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																								
H2491	016	0	1	02	01	H2491_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2491	016	0	1	02	01	H2491_016_0	5			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																								
H2491	016	0	1	02	01	H2491_016_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											160.73	25	25	25				160.73	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
H2491	016	0	1	02	01	H2491_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											43.84	40	40	40				43.84	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
H2491	016	0	1	02	01	H2491_016_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, Select Care Drugs																								
H2491	016	0	1	02	01	H2491_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																								
H2491	017	0	1	02	01	H2491_017_0	5			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																								
H2491	017	0	1	02	01	H2491_017_0	5			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																								
H2491	017	0	1	02	01	H2491_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.73	25	25	25				161.73	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
H2491	017	0	1	02	01	H2491_017_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											47.94	39	39	39				46.71	38	38	38										39	39	39				38	38	38			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
H2491	017	0	1	02	01	H2491_017_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, Select Care Drugs																								
H2491	017	0	1	02	01	H2491_017_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																								
H2491	021	0	1	02	01	H2491_021_0	5			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																								
H2491	021	0	1	02	01	H2491_021_0	5			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																								
H2491	021	0	1	02	01	H2491_021_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.64	25	25	25				157.64	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
H2491	021	0	1	02	01	H2491_021_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											44.43	35	35	35				44.43	35	35	35										35	35	35				35	35	35			35			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
H2491	021	0	1	02	01	H2491_021_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, Select Care Drugs																								
H2491	021	0	1	02	01	H2491_021_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																								
H2491	028	0	1	02	01	H2491_028_0	5			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																								
H2491	028	0	1	02	01	H2491_028_0	5			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																								
H2491	028	0	1	02	01	H2491_028_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.34	25	25	25				164.34	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
H2491	028	0	1	02	01	H2491_028_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											47.84	34	34	34				47.84	34	34	34										34	34	34				34	34	34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	028	0	1	02	01	H2491_028_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, Select Care Drugs																								
H2491	028	0	1	02	01	H2491_028_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																								
H2491	029	0	1	02	01	H2491_029_0	5			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																								
H2491	029	0	1	02	01	H2491_029_0	5			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																								
H2491	029	0	1	02	01	H2491_029_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.33	25	25	25				161.33	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
H2491	029	0	1	02	01	H2491_029_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											47.31	33	33	33				47.31	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	029	0	1	02	01	H2491_029_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, Select Care Drugs																								
H2491	029	0	1	02	01	H2491_029_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																								
H2506	001	0	1	48	05	H2506_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															
H2506	001	0	1	48	05	H2506_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															
H2506	001	0	1	48	05	H2506_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															
H2526	001	0	1	04	01	H2526_001_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										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	7			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
H2526	001	0	1	04	01	H2526_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H2526	001	0	1	04	01	H2526_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				40.00	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
H2526	001	0	1	04	01	H2526_001_0	7			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
H2526	003	0	1	04	01	H2526_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2526	003	0	1	04	01	H2526_003_0	7			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
H2526	003	0	1	04	01	H2526_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	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
H2526	003	0	1	04	01	H2526_003_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				46.00	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
H2526	003	0	1	04	01	H2526_003_0	7			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
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	4.90	0.00	4.90	0.00	4.90	0.00	4.90															
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	12.15	0.00	12.15	0.00	12.15	0.00	12.15															
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	100				1	2	31	60	100				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	100				2	2	31	60	100				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						2	2	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	8			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	005	1	1	01	01	H2563_005_1	8			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					8.00		20.00					0.00		0.00																20.00				8.00			0.67	0.27	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	005	1	1	01	01	H2563_005_1	8			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								45.00		112.50					40.00		100.00					40.00		80.00																45.00				40.00			1.50	1.33	1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	005	1	1	01	01	H2563_005_1	8			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					90.00		270.00					90.00		270.00																95.00				90.00			3.17	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	005	1	1	01	01	H2563_005_1	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1312.15	31						759.07	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	005	1	1	01	01	H2563_005_1	8			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	005	2	1	01	01	H2563_005_2	8			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	005	2	1	01	01	H2563_005_2	8			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					8.00		20.00					0.00		0.00																20.00				8.00			0.67	0.27	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	005	2	1	01	01	H2563_005_2	8			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								45.00		112.50					40.00		100.00					40.00		80.00																45.00				40.00			1.50	1.33	1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	005	2	1	01	01	H2563_005_2	8			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					90.00		270.00					90.00		270.00																95.00				90.00			3.17	3.00	3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	005	2	1	01	01	H2563_005_2	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1312.15	31						759.07	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	005	2	1	01	01	H2563_005_2	8			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	008	0	1	01	01	H2563_008_0	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	008	0	1	01	01	H2563_008_0	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	008	0	1	01	01	H2563_008_0	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	008	0	1	01	01	H2563_008_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	008	0	1	01	01	H2563_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											889.05	31						717.17	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	008	0	1	01	01	H2563_008_0	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	009	0	1	01	01	H2563_009_0	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	009	0	1	01	01	H2563_009_0	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	009	0	1	01	01	H2563_009_0	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	009	0	1	01	01	H2563_009_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	009	0	1	01	01	H2563_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1347.57	31						832.85	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	009	0	1	01	01	H2563_009_0	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	016	0	1	01	01	H2563_016_0	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	016	0	1	01	01	H2563_016_0	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	016	0	1	01	01	H2563_016_0	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	016	0	1	01	01	H2563_016_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	016	0	1	01	01	H2563_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1192.50	31						654.17	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	016	0	1	01	01	H2563_016_0	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	017	1	1	01	01	H2563_017_1	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	017	1	1	01	01	H2563_017_1	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	017	1	1	01	01	H2563_017_1	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	017	1	1	01	01	H2563_017_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	017	1	1	01	01	H2563_017_1	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1229.89	31						724.67	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	017	1	1	01	01	H2563_017_1	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	017	2	1	01	01	H2563_017_2	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	017	2	1	01	01	H2563_017_2	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	017	2	1	01	01	H2563_017_2	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	017	2	1	01	01	H2563_017_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50	35.00		87.50	35.00		70.00				35.00		35.00
H2563	017	2	1	01	01	H2563_017_2	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1229.89	31						724.67	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	017	2	1	01	01	H2563_017_2	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	018	0	1	01	01	H2563_018_0	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	018	0	1	01	01	H2563_018_0	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	018	0	1	01	01	H2563_018_0	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	018	0	1	01	01	H2563_018_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	018	0	1	01	01	H2563_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											778.41	31						453.51	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	018	0	1	01	01	H2563_018_0	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	022	0	1	01	01	H2563_022_0	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	022	0	1	01	01	H2563_022_0	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	022	0	1	01	01	H2563_022_0	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	022	0	1	01	01	H2563_022_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	022	0	1	01	01	H2563_022_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											513.42	31						444.66	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	022	0	1	01	01	H2563_022_0	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	023	0	1	01	01	H2563_023_0	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	023	0	1	01	01	H2563_023_0	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	023	0	1	01	01	H2563_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		117.50					42.00		105.00					42.00		84.00																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										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	023	0	1	01	01	H2563_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	023	0	1	01	01	H2563_023_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											513.26	31						444.54	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	023	0	1	01	01	H2563_023_0	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	024	0	1	01	01	H2563_024_0	7			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	024	0	1	01	01	H2563_024_0	7			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	024	0	1	01	01	H2563_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		117.50					42.00		105.00					42.00		84.00																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										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	024	0	1	01	01	H2563_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	024	0	1	01	01	H2563_024_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											516.47	31						447.54	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	024	0	1	01	01	H2563_024_0	7			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	025	0	1	01	01	H2563_025_0	8			Preferred Generic	4	01	3	2	1	1		110	01	110		1				30		100	2	2	30		100				30		31								5.00		12.50					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																								
H2563	025	0	1	01	01	H2563_025_0	8			Generic	4	01	3	2	2	1		110	01	110		1				30		90	2	2	30		90				30		31								20.00		50.00					10.00		25.00					0.00		0.00																20.00				10.00			0.67	0.33	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	025	0	1	01	01	H2563_025_0	8			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	2	2	30		90				30		31								47.00		117.50					42.00		105.00					42.00		84.00																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										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	025	0	1	01	01	H2563_025_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					95.00		285.00					95.00		285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00		0.00	0.00		0.00	0.00		0.00				0.00		0.00
H2563	025	0	1	01	01	H2563_025_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											507.09	31						438.33	31																							31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2563	025	0	1	01	01	H2563_025_0	8			Select Care Drugs	4	01	1	2	6	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	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				157.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	005	0	1	02	01	H2582_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				183.00	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
H2593	001	0	1	02	01	H2593_001_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	001	0	1	02	01	H2593_001_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H2593	001	0	1	02	01	H2593_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											98.08	25	25	25				78.47	20	20	20				20	20	20															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	70.00				35.00		35.00
H2593	001	0	1	02	01	H2593_001_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											74.10	25	25	25				74.10	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		35.00
H2593	001	0	1	02	01	H2593_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																								
H2593	001	0	1	02	01	H2593_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
H2593	003	0	1	01	01	H2593_003_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																								
H2593	003	0	1	01	01	H2593_003_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																								
H2593	003	0	1	01	01	H2593_003_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				95.63	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	70.00				35.00		35.00
H2593	003	0	1	01	01	H2593_003_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				49.67	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
H2593	003	0	1	01	01	H2593_003_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																								
H2593	003	0	1	01	01	H2593_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		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	005	0	1	02	01	H2593_005_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																								
H2593	005	0	1	02	01	H2593_005_0	5			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	02	01	H2593_005_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											85.28	25	25	25				68.22	20	20	20				20	20	20															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	70.00				35.00		35.00
H2593	005	0	1	02	01	H2593_005_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											69.27	25	25	25				69.27	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		35.00
H2593	005	0	1	02	01	H2593_005_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																								
H2593	005	0	1	02	01	H2593_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			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	02	01	H2593_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2593	006	0	1	02	01	H2593_006_0	5			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																								
H2593	006	0	1	02	01	H2593_006_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											90.27	20	20	20				67.70	15	15	15				15	15	15															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	70.00				35.00		35.00
H2593	006	0	1	02	01	H2593_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											63.97	25	25	25				63.97	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		35.00
H2593	006	0	1	02	01	H2593_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, Select Care Drugs																								
H2593	006	0	1	02	01	H2593_006_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			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	029	0	1	02	01	H2593_029_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																								
H2593	029	0	1	02	01	H2593_029_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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	029	0	1	02	01	H2593_029_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											46.67	20	20	20				46.67	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	70.00				35.00		35.00
H2593	029	0	1	02	01	H2593_029_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											59.82	35	35	35				59.82	35	35	35				35	35	35															35			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
H2593	029	0	1	02	01	H2593_029_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	029	0	1	02	01	H2593_029_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																								
H2593	031	0	1	02	01	H2593_031_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																								
H2593	031	0	1	02	01	H2593_031_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																								
H2593	031	0	1	02	01	H2593_031_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											40.83	15	15	15				27.22	10	10	10				10	10	10															15			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				35.00		35.00
H2593	031	0	1	02	01	H2593_031_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											86.09	25	25	25				68.87	20	20	20				20	20	20															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		35.00
H2593	031	0	1	02	01	H2593_031_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																								
H2593	031	0	1	02	01	H2593_031_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																								
H2593	032	0	1	01	01	H2593_032_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	1.00	2.00	3.00																			1.00	3.00	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																								
H2593	032	0	1	01	01	H2593_032_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	8.00	16.00	24.00																			8.00	24.00	24.00																8.00				8.00		0.27			0.27			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2593	032	0	1	01	01	H2593_032_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				55.07	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		35.00
H2593	032	0	1	01	01	H2593_032_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				54.16	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
H2593	032	0	1	01	01	H2593_032_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, Select Care Drugs																								
H2593	032	0	1	01	01	H2593_032_0	6		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	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																								
H2593	040	0	1	02	01	H2593_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								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	02	01	H2593_040_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					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	040	0	1	02	01	H2593_040_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											111.12	25	25	25				88.89	20	20	20				20	20	20															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	70.00				35.00		35.00
H2593	040	0	1	02	01	H2593_040_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											119.47	25	25	25				119.47	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		35.00
H2593	040	0	1	02	01	H2593_040_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																								
H2593	040	0	1	02	01	H2593_040_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			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	043	0	1	02	01	H2593_043_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	043	0	1	02	01	H2593_043_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																								
H2593	043	0	1	02	01	H2593_043_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											54.59	25	25	25				43.67	20	20	20				20	20	20															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		35.00
H2593	043	0	1	02	01	H2593_043_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											66.30	25	25	25				66.30	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		35.00
H2593	043	0	1	02	01	H2593_043_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	043	0	1	02	01	H2593_043_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																								
H2593	046	0	1	01	01	H2593_046_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34				1.24	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2593	046	0	1	01	01	H2593_046_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				14.96	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2593	046	0	1	01	01	H2593_046_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				63.77	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
H2593	046	0	1	01	01	H2593_046_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				55.52	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
H2593	046	0	1	01	01	H2593_046_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, Select Care Drugs																								
H2593	046	0	1	01	01	H2593_046_0	6		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	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																								
H2593	053	0	1	01	01	H2593_053_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	1.00	2.00	3.00																			1.00	3.00	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																								
H2593	053	0	1	01	01	H2593_053_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	6.00	12.00	18.00																			6.00	18.00	18.00																6.00				6.00		0.20			0.20			0.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2593	053	0	1	01	01	H2593_053_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				67.73	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
H2593	053	0	1	01	01	H2593_053_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				58.32	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
H2593	053	0	1	01	01	H2593_053_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, Select Care Drugs																								
H2593	053	0	1	01	01	H2593_053_0	6		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	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																								
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 Drug, Specialty Tier, Select Care 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					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 Drug, Specialty Tier, Select Care 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			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					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 Drug, Specialty Tier, Select Care 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 Drug, Specialty Tier, Select Care Drugs										35.00			35.00			35.00						35.00		35.00
H2610	005	0	1	01	01	H2610_005_0	4			Select Care 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 Drug, Specialty Tier, Select Care 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	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 Drug, Specialty Tier, Select Care 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	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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
H2610	006	0	1	01	01	H2610_006_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					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 Drug, Specialty Tier, Select Care 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	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					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 Drug, Specialty Tier, Select Care 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	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
H2610	006	0	1	01	01	H2610_006_0	5			Select Care 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 Drug, Specialty Tier, Select Care Drugs										0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
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 Drug, Specialty Tier, Select Care 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					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, Select Care 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 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					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 Drug, Specialty Tier, Select Care 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												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
H2610	011	0	1	01	01	H2610_011_0	4			Select Care 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 Drug, Specialty Tier, Select Care 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 Drug, Specialty Tier, Select Care 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			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					3.00	6.00	9.00							7.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										10.00	20.00	30.00	3.00	6.00	9.00			7.50				10.00		10.00
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 Drug, Specialty Tier, Select Care 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 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					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 Drug, Specialty Tier, Select Care 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												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
H2610	015	0	1	01	01	H2610_015_0	4			Select Care 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 Drug, Specialty Tier, Select Care 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 Drug, Specialty Tier, Select Care 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					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 Drug, Specialty Tier, Select Care 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			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					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 Drug, Specialty Tier, Select Care 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												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
H2610	016	0	1	01	01	H2610_016_0	4			Select Care 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 Drug, Specialty Tier, Select Care 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 Drug, 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			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					3.00	6.00	9.00							7.50																10.00				10.00			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			7.50				10.00		10.00
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 Drug, 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 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					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 Drug, 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												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
H2610	021	0	1	01	01	H2610_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					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										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	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					3.00	6.00	9.00							7.50																10.00				10.00			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			7.50				10.00		10.00
H2610	021	0	1	01	01	H2610_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					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
H2610	021	0	1	01	01	H2610_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					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 Drug, 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	4			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
H2610	023	0	1	01	01	H2610_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					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										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	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					3.00	6.00	9.00							7.50																10.00				10.00			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			7.50				10.00		10.00
H2610	023	0	1	01	01	H2610_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					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
H2610	023	0	1	01	01	H2610_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					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 Drug, 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	4			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
H2610	026	0	1	01	01	H2610_026_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 Drug, Specialty Tier, Select Care Drugs										4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H2610	026	0	1	01	01	H2610_026_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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
H2610	026	0	1	01	01	H2610_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					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, Select Care Drugs										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	026	0	1	01	01	H2610_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					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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	026	0	1	01	01	H2610_026_0	4			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, Select Care Drugs										35.00			35.00			35.00						35.00		35.00
H2610	026	0	1	01	01	H2610_026_0	4			Select Care 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 Drug, Specialty Tier, Select Care Drugs										0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H2610	027	0	1	01	01	H2610_027_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 Drug, Specialty Tier, Select Care Drugs										4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H2610	027	0	1	01	01	H2610_027_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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
H2610	027	0	1	01	01	H2610_027_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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	027	0	1	01	01	H2610_027_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					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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	027	0	1	01	01	H2610_027_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
H2610	027	0	1	01	01	H2610_027_0	4			Select Care 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 Drug, Specialty Tier, Select Care Drugs										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	8			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	12.50					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, Select Care Drugs																								
H2624	001	0	1	01	01	H2624_001_0	8			Generic	4	01	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								15.00	30.00	37.50					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	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	117.50					47.00	94.00	117.50					47.00	94.00	117.50																	47.00			47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2624	001	0	1	01	01	H2624_001_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	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, 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
H2624	001	0	1	01	01	H2624_001_0	8			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											643.25	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	8			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	004	0	1	01	01	H2624_004_0	9			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	25.00					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	9			Generic	4	01	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								20.00	40.00	50.00					5.00	10.00	12.50					5.00	10.00	12.50																	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	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	117.50					47.00	94.00	117.50					47.00	94.00	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	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2624	004	0	1	01	01	H2624_004_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											85.84	50	50	50				70.69	40	40	40				40	40	40																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
H2624	004	0	1	01	01	H2624_004_0	9			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											776.68	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	02	01	H2663_002_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	002	0	1	02	01	H2663_002_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	002	0	1	02	01	H2663_002_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.98	24	24	24				96.09	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
H2663	002	0	1	02	01	H2663_002_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.85	25	25	25				33.57	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	002	0	1	02	01	H2663_002_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.70	25						814.24	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
H2663	005	0	1	02	01	H2663_005_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	005	0	1	02	01	H2663_005_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2663	005	0	1	02	01	H2663_005_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.74	25	25	25				92.35	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	005	0	1	02	01	H2663_005_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.74	35	35	35				34.60	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
H2663	005	0	1	02	01	H2663_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1115.22	33						1389.68	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
H2663	006	0	1	02	01	H2663_006_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	006	0	1	02	01	H2663_006_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	006	0	1	02	01	H2663_006_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.03	24	24	24				100.29	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
H2663	006	0	1	02	01	H2663_006_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.40	25	25	25				37.90	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	006	0	1	02	01	H2663_006_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											694.80	25						673.47	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
H2663	017	0	1	02	01	H2663_017_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	017	0	1	02	01	H2663_017_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	017	0	1	02	01	H2663_017_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.23	24	24	24				102.91	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
H2663	017	0	1	02	01	H2663_017_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.47	25	25	25				34.04	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
H2663	017	0	1	02	01	H2663_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											779.61	25						654.98	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
H2663	021	0	1	02	01	H2663_021_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	021	0	1	02	01	H2663_021_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	021	0	1	02	01	H2663_021_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.50	24	24	24				100.64	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
H2663	021	0	1	02	01	H2663_021_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.30	25	25	25				34.97	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	021	0	1	02	01	H2663_021_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											787.42	25						899.91	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
H2663	023	0	1	02	01	H2663_023_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	023	0	1	02	01	H2663_023_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2663	023	0	1	02	01	H2663_023_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.30	25	25	25				110.61	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	023	0	1	02	01	H2663_023_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.44	26	26	26				28.19	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1010.49	30						1549.41	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
H2663	026	0	1	02	01	H2663_026_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	026	0	1	02	01	H2663_026_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	026	0	1	02	01	H2663_026_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.33	24	24	24				107.28	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
H2663	026	0	1	02	01	H2663_026_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.99	25	25	25				38.14	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	026	0	1	02	01	H2663_026_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											886.17	25						776.90	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
H2663	028	0	1	02	01	H2663_028_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	028	0	1	02	01	H2663_028_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	028	0	1	02	01	H2663_028_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.89	24	24	24				110.40	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
H2663	028	0	1	02	01	H2663_028_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.77	25	25	25				32.36	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
H2663	028	0	1	02	01	H2663_028_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											711.80	25						628.31	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
H2663	029	0	1	02	01	H2663_029_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	029	0	1	02	01	H2663_029_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	029	0	1	02	01	H2663_029_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.89	21	21	21				64.80	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	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	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.88	50	50	50				34.10	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
H2663	029	0	1	02	01	H2663_029_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1109.56	33						1085.95	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
H2663	034	0	1	01	01	H2663_034_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	034	0	1	01	01	H2663_034_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2663	034	0	1	01	01	H2663_034_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.03	25	25	25				101.54	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	034	0	1	01	01	H2663_034_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											39.96	26	26	26				32.65	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											976.99	30						935.49	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
H2663	038	0	1	01	01	H2663_038_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	038	0	1	01	01	H2663_038_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	038	0	1	01	01	H2663_038_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.61	24	24	24				101.48	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
H2663	038	0	1	01	01	H2663_038_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.42	25	25	25				34.14	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	038	0	1	01	01	H2663_038_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											758.20	25						741.60	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
H2663	039	0	1	01	01	H2663_039_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	039	0	1	01	01	H2663_039_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	039	0	1	01	01	H2663_039_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.35	24	24	24				97.52	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
H2663	039	0	1	01	01	H2663_039_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.09	25	25	25				30.27	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	039	0	1	01	01	H2663_039_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											693.92	25						759.84	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
H2663	040	0	1	01	01	H2663_040_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	040	0	1	01	01	H2663_040_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	040	0	1	01	01	H2663_040_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.89	24	24	24				101.96	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
H2663	040	0	1	01	01	H2663_040_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.47	25	25	25				38.17	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	040	0	1	01	01	H2663_040_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											684.88	25						759.73	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
H2663	041	0	1	02	01	H2663_041_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	041	0	1	02	01	H2663_041_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	041	0	1	02	01	H2663_041_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.66	24	24	24				100.88	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
H2663	041	0	1	02	01	H2663_041_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.30	25	25	25				37.11	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	041	0	1	02	01	H2663_041_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											821.00	25						769.65	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
H2663	042	0	1	01	01	H2663_042_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	042	0	1	01	01	H2663_042_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	042	0	1	01	01	H2663_042_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.83	24	24	24				102.94	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
H2663	042	0	1	01	01	H2663_042_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.01	25	25	25				35.50	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	042	0	1	01	01	H2663_042_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											768.22	25						785.40	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
H2663	043	0	1	02	01	H2663_043_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	043	0	1	02	01	H2663_043_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	043	0	1	02	01	H2663_043_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.55	24	24	24				104.22	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
H2663	043	0	1	02	01	H2663_043_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.24	25	25	25				33.16	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	043	0	1	02	01	H2663_043_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											716.26	25						641.81	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
H2663	052	0	1	01	01	H2663_052_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	052	0	1	01	01	H2663_052_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	052	0	1	01	01	H2663_052_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.46	24	24	24				102.25	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
H2663	052	0	1	01	01	H2663_052_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											43.63	25	25	25				41.53	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	052	0	1	01	01	H2663_052_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.18	25						739.03	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
H2663	053	0	1	01	01	H2663_053_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	053	0	1	01	01	H2663_053_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	053	0	1	01	01	H2663_053_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.46	24	24	24				102.25	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
H2663	053	0	1	01	01	H2663_053_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											43.64	25	25	25				41.55	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	053	0	1	01	01	H2663_053_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.08	25						738.47	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
H2663	054	0	1	01	01	H2663_054_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	054	0	1	01	01	H2663_054_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	054	0	1	01	01	H2663_054_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.50	24	24	24				102.25	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
H2663	054	0	1	01	01	H2663_054_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											43.60	25	25	25				41.37	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	054	0	1	01	01	H2663_054_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.73	25						739.25	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
H2663	055	0	1	01	01	H2663_055_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	055	0	1	01	01	H2663_055_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	055	0	1	01	01	H2663_055_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.50	24	24	24				102.25	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
H2663	055	0	1	01	01	H2663_055_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											43.60	25	25	25				41.37	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	055	0	1	01	01	H2663_055_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.74	25						739.63	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
H2663	056	0	1	01	01	H2663_056_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	056	0	1	01	01	H2663_056_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	056	0	1	01	01	H2663_056_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.51	24	24	24				102.25	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
H2663	056	0	1	01	01	H2663_056_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											43.59	25	25	25				41.33	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	056	0	1	01	01	H2663_056_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.87	25						738.78	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
H2663	057	0	1	02	01	H2663_057_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	057	0	1	02	01	H2663_057_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	057	0	1	02	01	H2663_057_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.27	24	24	24				103.23	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
H2663	057	0	1	02	01	H2663_057_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.97	25	25	25				41.81	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	057	0	1	02	01	H2663_057_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											754.75	25						749.01	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
H2663	061	0	1	02	01	H2663_061_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	061	0	1	02	01	H2663_061_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	061	0	1	02	01	H2663_061_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.36	24	24	24				102.17	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
H2663	061	0	1	02	01	H2663_061_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.69	25	25	25				33.12	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	061	0	1	02	01	H2663_061_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.18	25						759.87	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
H2663	062	0	1	02	01	H2663_062_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	062	0	1	02	01	H2663_062_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	062	0	1	02	01	H2663_062_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.41	24	24	24				102.17	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
H2663	062	0	1	02	01	H2663_062_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.63	25	25	25				33.02	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	062	0	1	02	01	H2663_062_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											798.25	25						761.29	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
H2663	063	0	1	02	01	H2663_063_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	063	0	1	02	01	H2663_063_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	063	0	1	02	01	H2663_063_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.29	24	24	24				102.17	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
H2663	063	0	1	02	01	H2663_063_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.75	25	25	25				33.24	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
H2663	063	0	1	02	01	H2663_063_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											795.95	25						759.65	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
H2663	064	0	1	01	01	H2663_064_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	064	0	1	01	01	H2663_064_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	064	0	1	01	01	H2663_064_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.46	24	24	24				102.25	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
H2663	064	0	1	01	01	H2663_064_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											43.64	25	25	25				41.54	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	064	0	1	01	01	H2663_064_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.09	25						738.47	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
H2663	065	0	1	01	01	H2663_065_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	065	0	1	01	01	H2663_065_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	065	0	1	01	01	H2663_065_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.36	24	24	24				102.17	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
H2663	065	0	1	01	01	H2663_065_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.69	25	25	25				33.12	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.18	25						760.51	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
H2663	067	0	1	01	01	H2663_067_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	067	0	1	01	01	H2663_067_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H2663	067	0	1	01	01	H2663_067_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.13	24	24	24				93.76	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
H2663	067	0	1	01	01	H2663_067_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.43	25	25	25				31.47	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	067	0	1	01	01	H2663_067_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											678.85	25						682.77	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
H2686	004	1	1	04	01	H2686_004_1	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	Preferred Generic, 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	004	1	1	04	01	H2686_004_1	6			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H2686	004	1	1	04	01	H2686_004_1	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				83.00	21	21	21																		21	21	21															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		35.00
H2686	004	1	1	04	01	H2686_004_1	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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
H2686	004	1	1	04	01	H2686_004_1	6			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
H2686	004	3	1	04	01	H2686_004_3	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
H2686	004	3	1	04	01	H2686_004_3	5			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H2686	004	3	1	04	01	H2686_004_3	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				83.00	21	21	21																		21	21	21															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		35.00
H2686	004	3	1	04	01	H2686_004_3	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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
H2686	004	3	1	04	01	H2686_004_3	5			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
H2686	005	1	1	04	01	H2686_005_1	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	Preferred Generic, 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	005	1	1	04	01	H2686_005_1	6			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H2686	005	1	1	04	01	H2686_005_1	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				75.00	21	21	21																		21	21	21															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		35.00
H2686	005	1	1	04	01	H2686_005_1	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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
H2686	005	1	1	04	01	H2686_005_1	6			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
H2686	005	2	1	04	01	H2686_005_2	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	Preferred Generic, 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	005	2	1	04	01	H2686_005_2	6			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H2686	005	2	1	04	01	H2686_005_2	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				75.00	21	21	21																		21	21	21															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		35.00
H2686	005	2	1	04	01	H2686_005_2	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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
H2686	005	2	1	04	01	H2686_005_2	6			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
H2686	006	1	1	04	01	H2686_006_1	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	006	1	1	04	01	H2686_006_1	7			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
H2686	006	1	1	04	01	H2686_006_1	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.00	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
H2686	006	1	1	04	01	H2686_006_1	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				50.00	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
H2686	006	1	1	04	01	H2686_006_1	7			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
H2686	006	2	1	04	01	H2686_006_2	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	006	2	1	04	01	H2686_006_2	7			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
H2686	006	2	1	04	01	H2686_006_2	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.00	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
H2686	006	2	1	04	01	H2686_006_2	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				50.00	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
H2686	006	2	1	04	01	H2686_006_2	7			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
H2686	008	0	1	04	01	H2686_008_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
H2686	008	0	1	04	01	H2686_008_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	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
H2686	008	0	1	04	01	H2686_008_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				60.00	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
H2686	008	0	1	04	01	H2686_008_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				46.00	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
H2686	008	0	1	04	01	H2686_008_0	8			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
H2686	009	0	1	04	01	H2686_009_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	009	0	1	04	01	H2686_009_0	7			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	009	0	1	04	01	H2686_009_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				61.00	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
H2686	009	0	1	04	01	H2686_009_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				47.00	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
H2686	009	0	1	04	01	H2686_009_0	7			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
H2686	010	0	1	04	01	H2686_010_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	010	0	1	04	01	H2686_010_0	7			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	010	0	1	04	01	H2686_010_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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
H2686	010	0	1	04	01	H2686_010_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				53.00	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
H2686	010	0	1	04	01	H2686_010_0	7			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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2694	001	0	1	04	01	H2694_001_0	6			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H2694	001	0	1	04	01	H2694_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																			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
H2694	001	0	1	04	01	H2694_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				97.40	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	70.00				35.00		35.00
H2694	001	0	1	04	01	H2694_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				739.68	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H2694	002	0	1	04	01	H2694_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2694	002	0	1	04	01	H2694_002_0	8			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H2694	002	0	1	04	01	H2694_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	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
H2694	002	0	1	04	01	H2694_002_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				93.19	29	29	29																		29	29	29															29			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
H2694	002	0	1	04	01	H2694_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				710.16	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H2697	001	0	1	01	01	H2697_001_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										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	7			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
H2697	001	0	1	01	01	H2697_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.00	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
H2697	001	0	1	01	01	H2697_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				35.00	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
H2697	001	0	1	01	01	H2697_001_0	7			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	002	0	1	01	01	H2697_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										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	7			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
H2697	002	0	1	01	01	H2697_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				73.00	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
H2697	002	0	1	01	01	H2697_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				40.00	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
H2697	002	0	1	01	01	H2697_002_0	7			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	003	0	1	01	01	H2697_003_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
H2697	003	0	1	01	01	H2697_003_0	5			Generic	4	11	3	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	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	9.00				3.00	6.00	7.50				3.00		3.00
H2697	003	0	1	01	01	H2697_003_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				79.00	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
H2697	003	0	1	01	01	H2697_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				39.00	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
H2697	003	0	1	01	01	H2697_003_0	5			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	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										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	7			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
H2697	004	0	1	01	01	H2697_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H2697	004	0	1	01	01	H2697_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				36.00	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
H2697	004	0	1	01	01	H2697_004_0	7			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	006	0	1	01	01	H2697_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.00	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
H2697	006	0	1	01	01	H2697_006_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				39.00	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
H2697	006	0	1	01	01	H2697_006_0	7			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	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										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	7			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
H2697	007	0	1	01	01	H2697_007_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H2697	007	0	1	01	01	H2697_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				37.00	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
H2697	007	0	1	01	01	H2697_007_0	7			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	009	0	1	01	01	H2697_009_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				76.00	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
H2697	009	0	1	01	01	H2697_009_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				39.00	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
H2697	009	0	1	01	01	H2697_009_0	7			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	003	0	1	01	01	H2715_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				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	003	0	1	01	01	H2715_003_0	10			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				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	003	0	1	01	01	H2715_003_0	10			Preferred Brand	4	11	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	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	003	0	1	01	01	H2715_003_0	10			Non-Preferred Drug	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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H2715	003	0	1	01	01	H2715_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				272.92	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	003	0	1	01	01	H2715_003_0	10			Select Care Drugs	4	11	1	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H2722	002	0	1	02	01	H2722_002_0	4			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	4			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	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					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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											37.97	50	50	50				36.30	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
H2722	002	0	1	02	01	H2722_002_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											777.15	33						554.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2722	004	0	1	02	01	H2722_004_0	4			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	4			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	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					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	004	0	1	02	01	H2722_004_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.81	50	50	50				49.41	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
H2722	004	0	1	02	01	H2722_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1021.71	33						765.96	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2722	005	0	1	02	01	H2722_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								10.00	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	4			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	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					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	005	0	1	02	01	H2722_005_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											55.55	50	50	50				64.85	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
H2722	005	0	1	02	01	H2722_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											834.64	29						460.64	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2737	001	0	1	04	01	H2737_001_0	6			Preferred Generic	4	11	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													10.00						0.00				5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2737	001	0	1	04	01	H2737_001_0	6			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								20.00	40.00	60.00					10.00	20.00	30.00													40.00						20.00				20.00				20.00			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			40.00			20.00	20.00		20.00
H2737	001	0	1	04	01	H2737_001_0	6			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													94.00						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	105.00			70.00			70.00	35.00		35.00
H2737	001	0	1	04	01	H2737_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	90	1	2						90	30		31											98.99	29	29	29				89.52	29	29	29												29						29			29			29								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	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	27						1.00	27																							27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00									35.00		35.00
H2775	105	0	1	04	01	H2775_105_0	4			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	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	20.00	30.00				0.00	0.00	0.00				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																								
H2775	105	0	1	04	01	H2775_105_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											150.66	25	25	25				150.66	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
H2775	105	0	1	04	01	H2775_105_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.81	49	49	49				77.81	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
H2775	105	0	1	04	01	H2775_105_0	4			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																								
H2775	105	0	1	04	01	H2775_105_0	4			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	4			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	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	20.00	30.00				0.00	0.00	0.00				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																								
H2775	106	0	1	04	01	H2775_106_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.09	25	25	25				156.09	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
H2775	106	0	1	04	01	H2775_106_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											72.43	42	42	42				72.43	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
H2775	106	0	1	04	01	H2775_106_0	4			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																								
H2775	106	0	1	04	01	H2775_106_0	4			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	109	0	1	04	01	H2775_109_0	5			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	5			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																								
H2775	109	0	1	04	01	H2775_109_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											149.17	25	25	25				149.17	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
H2775	109	0	1	04	01	H2775_109_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											59.81	50	50	50				59.81	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
H2775	109	0	1	04	01	H2775_109_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, Select Care Drugs																								
H2775	109	0	1	04	01	H2775_109_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																								
H2775	111	0	1	04	01	H2775_111_0	4			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	111	0	1	04	01	H2775_111_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	20.00	30.00				0.00	0.00	0.00				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																								
H2775	111	0	1	04	01	H2775_111_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.81	25	25	25				156.81	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
H2775	111	0	1	04	01	H2775_111_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.42	45	45	45				83.52	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
H2775	111	0	1	04	01	H2775_111_0	4			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																								
H2775	111	0	1	04	01	H2775_111_0	4			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	4			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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2775	113	0	1	04	01	H2775_113_0	4			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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2775	113	0	1	04	01	H2775_113_0	4			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											148.63	25	25	25				142.69	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
H2775	113	0	1	04	01	H2775_113_0	4			Non-Preferred Drug	3	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	200.00				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
H2775	113	0	1	04	01	H2775_113_0	4			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																								
H2775	113	0	1	04	01	H2775_113_0	4			Select Care Drugs	3	11	1	2	6	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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2802	001	0	1	02	01	H2802_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																								
H2802	001	0	1	02	01	H2802_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																								
H2802	001	0	1	02	01	H2802_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
H2802	001	0	1	02	01	H2802_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	001	0	1	02	01	H2802_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				197.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				182.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				175.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				197.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				151.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				186.00	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
H2802	025	0	1	02	01	H2802_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																								
H2802	025	0	1	02	01	H2802_025_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																								
H2802	025	0	1	02	01	H2802_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
H2802	025	0	1	02	01	H2802_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	025	0	1	02	01	H2802_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				195.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				165.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				188.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				201.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				195.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				190.00	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
H2802	034	0	1	02	01	H2802_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																								
H2802	034	0	1	02	01	H2802_034_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	034	0	1	02	01	H2802_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
H2802	034	0	1	02	01	H2802_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	034	0	1	02	01	H2802_034_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				202.00	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
H2802	035	0	1	02	01	H2802_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																								
H2802	035	0	1	02	01	H2802_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																								
H2802	035	0	1	02	01	H2802_035_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	035	0	1	02	01	H2802_035_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	035	0	1	02	01	H2802_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				207.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				142.00	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
H2802	049	0	1	02	01	H2802_049_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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	049	0	1	02	01	H2802_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
H2802	049	0	1	02	01	H2802_049_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	049	0	1	02	01	H2802_049_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				207.00	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
H2802	052	0	1	02	01	H2802_052_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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	052	0	1	02	01	H2802_052_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	052	0	1	02	01	H2802_052_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	052	0	1	02	01	H2802_052_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				166.00	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
H2802	054	0	1	02	01	H2802_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																								
H2802	054	0	1	02	01	H2802_054_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	054	0	1	02	01	H2802_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
H2802	054	0	1	02	01	H2802_054_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	054	0	1	02	01	H2802_054_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				174.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				170.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				199.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				160.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				195.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				204.00	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
H2802	061	0	1	02	01	H2802_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																								
H2802	061	0	1	02	01	H2802_061_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																								
H2802	061	0	1	02	01	H2802_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
H2802	061	0	1	02	01	H2802_061_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	061	0	1	02	01	H2802_061_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				170.00	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
H2802	068	0	1	02	01	H2802_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																								
H2802	068	0	1	02	01	H2802_068_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	068	0	1	02	01	H2802_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										25.00		75.00						75.00			65.00	25.00		25.00
H2802	068	0	1	02	01	H2802_068_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	068	0	1	02	01	H2802_068_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H2802	070	0	1	02	01	H2802_070_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	070	0	1	02	01	H2802_070_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																								
H2802	070	0	1	02	01	H2802_070_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
H2802	070	0	1	02	01	H2802_070_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	070	0	1	02	01	H2802_070_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				170.00	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
H2802	071	0	1	02	01	H2802_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																								
H2802	071	0	1	02	01	H2802_071_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																								
H2802	071	0	1	02	01	H2802_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
H2802	071	0	1	02	01	H2802_071_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	071	0	1	02	01	H2802_071_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				199.00	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
H2802	072	0	1	02	01	H2802_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																								
H2802	072	0	1	02	01	H2802_072_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	072	0	1	02	01	H2802_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
H2802	072	0	1	02	01	H2802_072_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	072	0	1	02	01	H2802_072_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				205.00	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
H2802	073	0	1	02	01	H2802_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																								
H2802	073	0	1	02	01	H2802_073_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																								
H2802	073	0	1	02	01	H2802_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
H2802	073	0	1	02	01	H2802_073_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	073	0	1	02	01	H2802_073_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
H2802	074	0	1	02	01	H2802_074_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	074	0	1	02	01	H2802_074_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	074	0	1	02	01	H2802_074_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	074	0	1	02	01	H2802_074_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H2802	074	0	1	02	01	H2802_074_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H2816	013	0	1	09	04	H2816_013_0	5			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	5			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																								
H2816	013	0	1	09	04	H2816_013_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.86	25	25	25				151.86	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
H2816	013	0	1	09	04	H2816_013_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											69.31	46	46	46				67.80	45	45	45										46	46	46				45	45	45			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
H2816	013	0	1	09	04	H2816_013_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, Select Care Drugs																								
H2816	013	0	1	09	04	H2816_013_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																								
H2816	019	0	1	09	04	H2816_019_0	5			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	019	0	1	09	04	H2816_019_0	5			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																								
H2816	019	0	1	09	04	H2816_019_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											146.25	25	25	25				146.25	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
H2816	019	0	1	09	04	H2816_019_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											70.56	45	45	45				70.56	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
H2816	019	0	1	09	04	H2816_019_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, Select Care Drugs																								
H2816	019	0	1	09	04	H2816_019_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																								
H2819	001	0	1	01	01	H2819_001_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	100		1	30	60	100				2	2			100				30		31				1.28	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	6		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				5.60	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	6		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				2	2			100				30		31				95.35	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	001	0	1	01	01	H2819_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				2	2			100				30		31				73.18	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	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				488.34	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	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				5.42	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	100				2	2			100				30		31				95.88	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	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	100				2	2			100				30		31				68.13	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				489.63	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	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				5.47	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	100				2	2			100				30		31				96.87	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	100				2	2			100				30		31				78.43	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				488.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2836	005	0	1	04	01	H2836_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																								
H2836	005	0	1	04	01	H2836_005_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H2836	005	0	1	04	01	H2836_005_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											69.42	20	20	20				69.42	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	70.00				35.00		35.00
H2836	005	0	1	04	01	H2836_005_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											70.40	35	35	35				70.40	35	35	35				35	35	35															35			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
H2836	005	0	1	04	01	H2836_005_0	7			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																								
H2836	005	0	1	04	01	H2836_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																								
H2915	003	0	1	01	01	H2915_003_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																								
H2915	003	0	1	01	01	H2915_003_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	003	0	1	01	01	H2915_003_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											162.18	25	25	25				162.18	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
H2915	003	0	1	01	01	H2915_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											56.28	39	39	39				54.83	38	38	38										39	39	39				38	38	38			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
H2915	003	0	1	01	01	H2915_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, Select Care Drugs																								
H2915	003	0	1	01	01	H2915_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																								
H2915	011	0	1	01	01	H2915_011_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2915	011	0	1	01	01	H2915_011_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2915	011	0	1	01	01	H2915_011_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											139.10	22	22	22				139.10	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
H2915	011	0	1	01	01	H2915_011_0	6			Non-Preferred Drug	3	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	200.00				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
H2915	011	0	1	01	01	H2915_011_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																								
H2915	011	0	1	01	01	H2915_011_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																								
H2915	016	0	1	01	01	H2915_016_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																								
H2915	016	0	1	01	01	H2915_016_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.89	25	25	25				156.89	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
H2915	016	0	1	01	01	H2915_016_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											55.18	38	38	38				53.73	37	37	37										38	38	38				37	37	37			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
H2915	016	0	1	01	01	H2915_016_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, Select Care Drugs																								
H2915	016	0	1	01	01	H2915_016_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																								
H2923	001	0	1	01	01	H2923_001_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										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	7			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
H2923	001	0	1	01	01	H2923_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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
H2923	001	0	1	01	01	H2923_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				38.00	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
H2923	001	0	1	01	01	H2923_001_0	7			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
H2923	003	0	1	01	01	H2923_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2923	003	0	1	01	01	H2923_003_0	7			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
H2923	003	0	1	01	01	H2923_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H2923	003	0	1	01	01	H2923_003_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				44.00	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
H2923	003	0	1	01	01	H2923_003_0	7			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
H2923	004	0	1	01	01	H2923_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2923	004	0	1	01	01	H2923_004_0	7			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
H2923	004	0	1	01	01	H2923_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				62.00	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
H2923	004	0	1	01	01	H2923_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				48.00	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
H2923	004	0	1	01	01	H2923_004_0	7			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
H2923	005	0	1	01	01	H2923_005_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
H2923	005	0	1	01	01	H2923_005_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	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
H2923	005	0	1	01	01	H2923_005_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				51.00	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
H2923	005	0	1	01	01	H2923_005_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				51.00	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
H2923	005	0	1	01	01	H2923_005_0	8			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
H2923	006	0	1	01	01	H2923_006_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
H2923	006	0	1	01	01	H2923_006_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	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
H2923	006	0	1	01	01	H2923_006_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				51.00	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
H2923	006	0	1	01	01	H2923_006_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				51.00	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
H2923	006	0	1	01	01	H2923_006_0	8			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
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								15.00	30.00	45.00					10.00	20.00	30.00							37.50																15.00				15.00			0.50	0.33				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										15.00	30.00	45.00	10.00	20.00	30.00			37.50				15.00		15.00
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					47.00	94.00	141.00							117.50																47.00				47.00			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			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					100.00	200.00	300.00							250.00																100.00				100.00			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			105.00				35.00		35.00
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
H2960	012	0	1	01	01	H2960_012_0	5			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				2	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	012	0	1	01	01	H2960_012_0	5			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				2	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	5			Preferred Brand	4	10	1	2	3	1	111		01	101		1	30	60	100				2	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	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	101		1	30	60	100				2	2		60	100				30		31				92.27	50	50	50																			50	50															50			50								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	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										35.00												35.00		35.00
H2960	012	0	1	01	01	H2960_012_0	5			Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				2	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	5			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				2	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	5			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				2	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	5			Preferred Brand	4	10	1	2	3	1	111		01	101		1	30	60	100				2	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	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	101		1	30	60	100				2	2		60	100				30		31				79.80	50	50	50																			50	50															50			50								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	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										35.00												35.00		35.00
H2960	018	0	1	01	01	H2960_018_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	101		1	30	60	100				2	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	5			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				2	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	5			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				2	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	5			Preferred Brand	4	10	1	2	3	1	111		01	101		1	30	60	100				2	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	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	101		1	30	60	100				2	2		60	100				30		31				83.90	50	50	50																			50	50															50			50								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	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										35.00												35.00		35.00
H2960	019	0	1	01	01	H2960_019_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	101		1	30	60	100				2	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			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				2	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			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				2	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				2	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	1	4	1	111		01	101		1	30	60	100				2	2		60	100				30		31				88.18	50	50	50																			50	50															50			50								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			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										35.00												35.00		35.00
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				2	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																								
H2962	001	0	1	01	01	H2962_001_0	9			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 Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H2962	001	0	1	01	01	H2962_001_0	9			Generic	4	11	1	2	2	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																								
H2962	001	0	1	01	01	H2962_001_0	9			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00		90.00						60.00				30.00		30.00
H2962	001	0	1	01	01	H2962_001_0	9			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2962	001	0	1	01	01	H2962_001_0	9			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										35.00												35.00		35.00
H2962	021	0	1	01	01	H2962_021_0	9			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 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	9			Generic	4	11	1	2	2	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																								
H2962	021	0	1	01	01	H2962_021_0	9			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	021	0	1	01	01	H2962_021_0	9			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	021	0	1	01	01	H2962_021_0	9			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										35.00												35.00		35.00
H2962	021	0	1	01	01	H2962_021_0	9			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, 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	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	023	0	1	01	01	H2962_023_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	023	0	1	01	01	H2962_023_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	023	0	1	01	01	H2962_023_0	10			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										35.00												35.00		35.00
H2962	023	0	1	01	01	H2962_023_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, 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	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	025	0	1	01	01	H2962_025_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	025	0	1	01	01	H2962_025_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	025	0	1	01	01	H2962_025_0	10			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										35.00												35.00		35.00
H2962	025	0	1	01	01	H2962_025_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, 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	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	026	0	1	01	01	H2962_026_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	026	0	1	01	01	H2962_026_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	026	0	1	01	01	H2962_026_0	10			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										35.00												35.00		35.00
H2962	026	0	1	01	01	H2962_026_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										10.00		30.00						20.00				10.00		10.00
H2962	028	0	1	01	01	H2962_028_0	10			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 Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H2962	028	0	1	01	01	H2962_028_0	10			Generic	4	11	1	2	2	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																								
H2962	028	0	1	01	01	H2962_028_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H2962	028	0	1	01	01	H2962_028_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2962	028	0	1	01	01	H2962_028_0	10			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										35.00												35.00		35.00
H2962	029	0	1	01	01	H2962_029_0	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	029	0	1	01	01	H2962_029_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	029	0	1	01	01	H2962_029_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	029	0	1	01	01	H2962_029_0	10			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										35.00												35.00		35.00
H2962	029	0	1	01	01	H2962_029_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, 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	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	033	0	1	01	01	H2962_033_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	033	0	1	01	01	H2962_033_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	80.00		240.00																					160.00																80.00				80.00		2.67						2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	033	0	1	01	01	H2962_033_0	10			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										35.00												35.00		35.00
H2962	033	0	1	01	01	H2962_033_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										10.00		30.00						20.00				10.00		10.00
H2962	035	0	1	01	01	H2962_035_0	13		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				1	2			100				30		31					25		25																				25															25			25								Preferred Generic, 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	13		N	Generic	4	11	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H2962	035	0	1	01	01	H2962_035_0	13		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Preferred Generic, 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	13		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H2962	035	0	1	01	01	H2962_035_0	13		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, Supplemental Drugs										35.00												35.00		35.00
H2962	035	0	1	01	01	H2962_035_0	13		N	Supplemental Drugs	4	01	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																								
H2962	036	0	1	01	01	H2962_036_0	13		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				1	2			100				30		31					25		25																				25															25			25								Preferred Generic, 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	13		N	Generic	4	11	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H2962	036	0	1	01	01	H2962_036_0	13		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Preferred Generic, 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	13		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H2962	036	0	1	01	01	H2962_036_0	13		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, Supplemental Drugs										35.00												35.00		35.00
H2962	036	0	1	01	01	H2962_036_0	13		N	Supplemental Drugs	4	01	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																								
H2962	045	0	1	01	01	H2962_045_0	9			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 Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H2962	045	0	1	01	01	H2962_045_0	9			Generic	4	11	1	2	2	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																								
H2962	045	0	1	01	01	H2962_045_0	9			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00		90.00						60.00				30.00		30.00
H2962	045	0	1	01	01	H2962_045_0	9			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2962	045	0	1	01	01	H2962_045_0	9			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										35.00												35.00		35.00
H2962	046	0	1	01	01	H2962_046_0	10			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 Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H2962	046	0	1	01	01	H2962_046_0	10			Generic	4	11	1	2	2	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																								
H2962	046	0	1	01	01	H2962_046_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H2962	046	0	1	01	01	H2962_046_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2962	046	0	1	01	01	H2962_046_0	10			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										35.00												35.00		35.00
H2962	047	0	1	01	01	H2962_047_0	11			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 Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H2962	047	0	1	01	01	H2962_047_0	11			Generic	4	11	1	2	2	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																								
H2962	047	0	1	01	01	H2962_047_0	11			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00		75.00						50.00				25.00		25.00
H2962	047	0	1	01	01	H2962_047_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	75.00		225.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H2962	047	0	1	01	01	H2962_047_0	11			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										35.00												35.00		35.00
H2962	050	0	1	01	01	H2962_050_0	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	050	0	1	01	01	H2962_050_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	050	0	1	01	01	H2962_050_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	050	0	1	01	01	H2962_050_0	10			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										35.00												35.00		35.00
H2962	050	0	1	01	01	H2962_050_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, 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	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	051	0	1	01	01	H2962_051_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	051	0	1	01	01	H2962_051_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	051	0	1	01	01	H2962_051_0	10			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										35.00												35.00		35.00
H2962	051	0	1	01	01	H2962_051_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, 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	10			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 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	10			Generic	4	11	1	2	2	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																								
H2962	052	0	1	01	01	H2962_052_0	10			Preferred Brand	4	11	1	2	3	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	052	0	1	01	01	H2962_052_0	10			Non-Preferred Drug	4	11	1	2	4	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H2962	052	0	1	01	01	H2962_052_0	10			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										35.00												35.00		35.00
H2962	052	0	1	01	01	H2962_052_0	10			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										10.00		30.00						20.00				10.00		10.00
H3038	001	0	1	01	01	H3038_001_0	11		N	Preferred Generic	4	01	1	1	1	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 Drug, Specialty Tier																								
H3038	001	0	1	01	01	H3038_001_0	11		N	Generic	4	01	1	1	2	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 Drug, Specialty Tier																								
H3038	001	0	1	01	01	H3038_001_0	11		N	Preferred Brand	4	10	1	1	3	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 Drug, Specialty Tier										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3038	001	0	1	01	01	H3038_001_0	11		N	Non-Preferred Drug	4	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 Drug, Specialty Tier										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3038	001	0	1	01	01	H3038_001_0	11		N	Specialty Tier	4	11	1	1	5	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 Drug, Specialty Tier										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3041	001	0	1	01	01	H3041_001_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.00	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
H3041	001	0	1	01	01	H3041_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				38.00	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
H3041	001	0	1	01	01	H3041_001_0	7			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
H3041	003	0	1	01	01	H3041_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
H3041	003	0	1	01	01	H3041_003_0	8			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	003	0	1	01	01	H3041_003_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.00	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
H3041	003	0	1	01	01	H3041_003_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				54.00	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
H3041	003	0	1	01	01	H3041_003_0	8			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
H3047	001	0	1	04	01	H3047_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																								
H3047	001	0	1	04	01	H3047_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H3047	001	0	1	04	01	H3047_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											161.52	25	25	25				161.52	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
H3047	001	0	1	04	01	H3047_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											72.91	40	40	40				72.91	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
H3047	001	0	1	04	01	H3047_001_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, Select Care Drugs																								
H3047	001	0	1	04	01	H3047_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																								
H3047	002	0	1	04	01	H3047_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																								
H3047	002	0	1	04	01	H3047_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H3047	002	0	1	04	01	H3047_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.38	25	25	25				158.38	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
H3047	002	0	1	04	01	H3047_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											60.49	39	39	39				58.93	38	38	38										39	39	39				38	38	38			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
H3047	002	0	1	04	01	H3047_002_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, Select Care Drugs																								
H3047	002	0	1	04	01	H3047_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																								
H3071	002	0	1	01	01	H3071_002_0	11			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	11			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				17.00				17.00			0.57	0.00		0.57	0.00	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3071	002	0	1	01	01	H3071_002_0	11			Preferred Brand	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	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	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	11			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.00	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
H3080	001	0	1	01	01	H3080_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				37.00	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
H3080	001	0	1	01	01	H3080_001_0	7			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
H3080	002	0	1	01	01	H3080_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										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	7			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
H3080	002	0	1	01	01	H3080_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				77.00	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
H3080	002	0	1	01	01	H3080_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				42.00	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
H3080	002	0	1	01	01	H3080_002_0	7			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
H3113	008	0	1	02	01	H3113_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																								
H3113	008	0	1	02	01	H3113_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																								
H3113	008	0	1	02	01	H3113_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
H3113	008	0	1	02	01	H3113_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3113	008	0	1	02	01	H3113_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				163.00	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
H3124	001	0	1	04	01	H3124_001_0	23			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																								
H3124	001	0	1	04	01	H3124_001_0	23			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	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																								
H3124	001	0	1	04	01	H3124_001_0	23			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H3124	001	0	1	04	01	H3124_001_0	23			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				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
H3124	001	0	1	04	01	H3124_001_0	23			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										35.00						35.00						35.00		35.00
H3124	002	0	1	04	01	H3124_002_0	24			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																								
H3124	002	0	1	04	01	H3124_002_0	24			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	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																								
H3124	002	0	1	04	01	H3124_002_0	24			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H3124	002	0	1	04	01	H3124_002_0	24			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				100.00	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	70.00				35.00		35.00
H3124	002	0	1	04	01	H3124_002_0	24			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										35.00						35.00						35.00		35.00
H3138	001	0	1	04	01	H3138_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								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										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H3138	001	0	1	04	01	H3138_001_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				5.00			0.66	0.16	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		5.00
H3138	001	0	1	04	01	H3138_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								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	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										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	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										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	10			Vaccines	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																								
H3138	002	0	1	04	01	H3138_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								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										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H3138	002	0	1	04	01	H3138_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					5.00	10.00	15.00					0.00	0.00	0.00																20.00				5.00			0.66	0.16	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		5.00
H3138	002	0	1	04	01	H3138_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					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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	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										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	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										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	10			Vaccines	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																								
H3138	003	0	1	04	01	H3138_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								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										15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H3138	003	0	1	04	01	H3138_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					5.00	10.00	15.00					0.00	0.00	0.00																20.00				5.00			0.66	0.16	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		5.00
H3138	003	0	1	04	01	H3138_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	135.00																47.00				45.00			1.56	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	003	0	1	04	01	H3138_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	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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	003	0	1	04	01	H3138_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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	003	0	1	04	01	H3138_003_0	9			Vaccines	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																								
H3146	001	0	1	02	01	H3146_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	001	0	1	02	01	H3146_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	001	0	1	02	01	H3146_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.84	25	25	25				91.71	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
H3146	001	0	1	02	01	H3146_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.14	35	35	35				24.99	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
H3146	001	0	1	02	01	H3146_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1102.53	33						1011.61	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
H3146	004	0	1	02	01	H3146_004_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	004	0	1	02	01	H3146_004_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	004	0	1	02	01	H3146_004_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.47	25	25	25				92.35	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
H3146	004	0	1	02	01	H3146_004_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.33	35	35	35				30.85	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
H3146	004	0	1	02	01	H3146_004_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											981.50	33						1019.97	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
H3146	006	0	1	01	01	H3146_006_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	006	0	1	01	01	H3146_006_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	006	0	1	01	01	H3146_006_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.52	25	25	25				109.35	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
H3146	006	0	1	01	01	H3146_006_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											45.69	26	26	26				36.92	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1082.39	30						875.07	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
H3146	007	0	1	02	01	H3146_007_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	007	0	1	02	01	H3146_007_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	007	0	1	02	01	H3146_007_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.53	25	25	25				89.21	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
H3146	007	0	1	02	01	H3146_007_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.23	35	35	35				26.23	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
H3146	007	0	1	02	01	H3146_007_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											983.91	33						906.78	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
H3146	011	0	1	01	01	H3146_011_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	011	0	1	01	01	H3146_011_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	011	0	1	01	01	H3146_011_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.79	25	25	25				105.08	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
H3146	011	0	1	01	01	H3146_011_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.05	26	26	26				39.96	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											985.90	30						842.78	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
H3146	012	0	1	01	01	H3146_012_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	012	0	1	01	01	H3146_012_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	012	0	1	01	01	H3146_012_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.64	25	25	25				102.69	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
H3146	012	0	1	01	01	H3146_012_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											44.29	26	26	26				39.09	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											925.15	30						891.41	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
H3146	014	0	1	02	01	H3146_014_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	014	0	1	02	01	H3146_014_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	014	0	1	02	01	H3146_014_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.43	25	25	25				86.69	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
H3146	014	0	1	02	01	H3146_014_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.74	35	35	35				24.85	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
H3146	014	0	1	02	01	H3146_014_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1213.64	33						1215.68	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
H3146	021	0	1	01	01	H3146_021_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3146	021	0	1	01	01	H3146_021_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3146	021	0	1	01	01	H3146_021_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.95	25	25	25				80.65	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
H3146	021	0	1	01	01	H3146_021_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.35	35	35	35				28.65	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
H3146	021	0	1	01	01	H3146_021_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1109.58	33						1065.95	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
H3152	022	0	1	02	01	H3152_022_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	022	0	1	02	01	H3152_022_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	022	0	1	02	01	H3152_022_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.53	24	24	24				115.67	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
H3152	022	0	1	02	01	H3152_022_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.51	25	25	25				38.15	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
H3152	022	0	1	02	01	H3152_022_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1031.04	25						708.90	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
H3152	048	0	1	02	01	H3152_048_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	048	0	1	02	01	H3152_048_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	048	0	1	02	01	H3152_048_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.26	24	24	24				118.27	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
H3152	048	0	1	02	01	H3152_048_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.73	25	25	25				43.54	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
H3152	048	0	1	02	01	H3152_048_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											991.61	25						642.90	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
H3152	080	0	1	02	01	H3152_080_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	080	0	1	02	01	H3152_080_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	080	0	1	02	01	H3152_080_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.45	24	24	24				118.95	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
H3152	080	0	1	02	01	H3152_080_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.55	25	25	25				38.96	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
H3152	080	0	1	02	01	H3152_080_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											767.29	25						633.40	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
H3152	082	0	1	01	01	H3152_082_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	082	0	1	01	01	H3152_082_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	082	0	1	01	01	H3152_082_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.76	22	22	22				106.66	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.49	25	25	25				36.71	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
H3152	082	0	1	01	01	H3152_082_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											755.37	27						651.24	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
H3152	098	0	1	01	01	H3152_098_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	098	0	1	01	01	H3152_098_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3152	098	0	1	01	01	H3152_098_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											98.70	24	24	24				130.24	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
H3152	098	0	1	01	01	H3152_098_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.45	25	25	25				42.95	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
H3152	098	0	1	01	01	H3152_098_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											989.43	25						924.92	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
H3170	003	1	1	01	01	H3170_003_1	9			Preferred Generic	4	01	3	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	8.00	0.00				4.00				4.00		0.13				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	12.00	4.00	8.00	0.00	4.00		4.00
H3170	003	1	1	01	01	H3170_003_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																									14.00	28.00	42.00				14.00	28.00	0.00				14.00				14.00		0.47				0.47	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00				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	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	131.00				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	95.00	35.00		35.00
H3170	003	1	1	01	01	H3170_003_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	290.00				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	95.00	35.00		35.00
H3170	003	1	1	01	01	H3170_003_1	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				434.08	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3170	003	2	1	01	01	H3170_003_2	9			Preferred Generic	4	01	3	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	8.00	0.00				4.00				4.00		0.13				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	12.00	4.00	8.00	0.00	4.00		4.00
H3170	003	2	1	01	01	H3170_003_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																									14.00	28.00	42.00				14.00	28.00	0.00				14.00				14.00		0.47				0.47	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00				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	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	131.00				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	95.00	35.00		35.00
H3170	003	2	1	01	01	H3170_003_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	290.00				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	95.00	35.00		35.00
H3170	003	2	1	01	01	H3170_003_2	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				434.08	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3186	001	0	1	04	01	H3186_001_0	4			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	2	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																								
H3186	001	0	1	04	01	H3186_001_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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	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										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
H3186	001	0	1	04	01	H3186_001_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	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	4			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											83.16	50	50	50				82.20	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
H3186	001	0	1	04	01	H3186_001_0	4			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											656.85	30	30	30				703.98	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	4			Select Care Drugs	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	0.00				0.00				0.00			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	4			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	2	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																								
H3186	002	0	1	04	01	H3186_002_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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	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										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
H3186	002	0	1	04	01	H3186_002_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	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	4			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											92.52	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
H3186	002	0	1	04	01	H3186_002_0	4			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											712.73	29	29	29				741.81	29	29	29										29	29	29				29	29	29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3186	002	0	1	04	01	H3186_002_0	4			Select Care Drugs	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	0.00				0.00				0.00			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	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 Drug, 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	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					3.00	6.00	9.00							7.50																10.00				10.00			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			7.50				10.00		10.00
H3189	001	0	1	01	01	H3189_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 Drug, 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	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					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 Drug, 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	4			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
H3192	001	0	1	02	01	H3192_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	001	0	1	02	01	H3192_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	001	0	1	02	01	H3192_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.03	24	24	24				111.50	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
H3192	001	0	1	02	01	H3192_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.30	25	25	25				35.79	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
H3192	001	0	1	02	01	H3192_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											929.23	25						773.65	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
H3192	002	0	1	02	01	H3192_002_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	002	0	1	02	01	H3192_002_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	002	0	1	02	01	H3192_002_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.39	24	24	24				107.04	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
H3192	002	0	1	02	01	H3192_002_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.09	25	25	25				33.23	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
H3192	002	0	1	02	01	H3192_002_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											622.45	25						737.98	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
H3192	003	0	1	02	01	H3192_003_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	003	0	1	02	01	H3192_003_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	003	0	1	02	01	H3192_003_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.89	24	24	24				112.66	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
H3192	003	0	1	02	01	H3192_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.08	25	25	25				31.69	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
H3192	003	0	1	02	01	H3192_003_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											846.55	25						678.16	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
H3192	004	0	1	02	01	H3192_004_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	004	0	1	02	01	H3192_004_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	004	0	1	02	01	H3192_004_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.60	24	24	24				108.15	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
H3192	004	0	1	02	01	H3192_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.36	25	25	25				33.47	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
H3192	004	0	1	02	01	H3192_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.35	25						743.41	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
H3192	005	0	1	02	01	H3192_005_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	005	0	1	02	01	H3192_005_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	005	0	1	02	01	H3192_005_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.06	24	24	24				108.70	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
H3192	005	0	1	02	01	H3192_005_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.05	25	25	25				35.75	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
H3192	005	0	1	02	01	H3192_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											799.05	25						751.86	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
H3192	006	0	1	02	01	H3192_006_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	006	0	1	02	01	H3192_006_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	006	0	1	02	01	H3192_006_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.76	24	24	24				111.66	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
H3192	006	0	1	02	01	H3192_006_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.43	25	25	25				31.71	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
H3192	006	0	1	02	01	H3192_006_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											916.92	25						725.31	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
H3192	010	0	1	02	01	H3192_010_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	010	0	1	02	01	H3192_010_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	010	0	1	02	01	H3192_010_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.96	24	24	24				103.55	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
H3192	010	0	1	02	01	H3192_010_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.19	25	25	25				34.96	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
H3192	010	0	1	02	01	H3192_010_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											749.34	25						748.07	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
H3192	011	0	1	02	01	H3192_011_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	011	0	1	02	01	H3192_011_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	011	0	1	02	01	H3192_011_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.46	24	24	24				105.02	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
H3192	011	0	1	02	01	H3192_011_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.81	25	25	25				36.57	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
H3192	011	0	1	02	01	H3192_011_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											754.92	25						744.95	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
H3192	013	0	1	02	01	H3192_013_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	013	0	1	02	01	H3192_013_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	013	0	1	02	01	H3192_013_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.46	24	24	24				96.14	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
H3192	013	0	1	02	01	H3192_013_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.87	25	25	25				33.58	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
H3192	013	0	1	02	01	H3192_013_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											713.65	25						646.53	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
H3192	020	0	1	02	01	H3192_020_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	020	0	1	02	01	H3192_020_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	020	0	1	02	01	H3192_020_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.67	24	24	24				100.27	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
H3192	020	0	1	02	01	H3192_020_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											38.28	25	25	25				33.75	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
H3192	020	0	1	02	01	H3192_020_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											753.62	25						761.97	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
H3192	021	0	1	02	01	H3192_021_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	021	0	1	02	01	H3192_021_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3192	021	0	1	02	01	H3192_021_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.55	22	22	22				40.59	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	021	0	1	02	01	H3192_021_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.99	25	25	25				43.73	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
H3192	021	0	1	02	01	H3192_021_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											347.45	25						305.86	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
H3204	001	0	1	01	01	H3204_001_0	4			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	4			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	4			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	4			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31				45.00	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		35.00
H3204	001	0	1	01	01	H3204_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 Drug, Specialty Tier																								
H3204	007	0	1	01	01	H3204_007_0	4			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	4			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	4			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										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	4			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31				45.00	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		35.00
H3204	007	0	1	01	01	H3204_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																								
H3204	013	4	1	01	01	H3204_013_4	4		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	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				4.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3204	013	4	1	01	01	H3204_013_4	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				95.00	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
H3204	013	4	1	01	01	H3204_013_4	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				45.00	26	26	26																		26	26	26															26			26								Preferred Generic, 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	4		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	4		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	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				4.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3204	013	5	1	01	01	H3204_013_5	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				95.00	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
H3204	013	5	1	01	01	H3204_013_5	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				45.00	26	26	26																		26	26	26															26			26								Preferred Generic, 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	4		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	6	1	01	01	H3204_013_6	4		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	6	1	01	01	H3204_013_6	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				4.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3204	013	6	1	01	01	H3204_013_6	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				95.00	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
H3204	013	6	1	01	01	H3204_013_6	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				45.00	26	26	26																		26	26	26															26			26								Preferred Generic, 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	6	1	01	01	H3204_013_6	4		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	4			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	4			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	4			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	4			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31				45.00	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		35.00
H3204	015	0	1	02	01	H3204_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 Drug, Specialty Tier																								
H3204	016	0	1	01	01	H3204_016_0	4			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	016	0	1	01	01	H3204_016_0	4			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				4.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3204	016	0	1	01	01	H3204_016_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				95.00	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
H3204	016	0	1	01	01	H3204_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				45.00	26	26	26																		26	26	26															26			26								Preferred Generic, 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	016	0	1	01	01	H3204_016_0	4			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																								
H3219	001	0	1	04	01	H3219_001_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	001	0	1	04	01	H3219_001_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3219	001	0	1	04	01	H3219_001_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.55	25	25	25				103.05	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
H3219	001	0	1	04	01	H3219_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.08	26	26	26				37.60	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											819.63	30						916.06	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	002	0	1	04	01	H3219_002_0	5			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	002	0	1	04	01	H3219_002_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3219	002	0	1	04	01	H3219_002_0	5			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.86	25	25	25				110.60	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
H3219	002	0	1	04	01	H3219_002_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											36.28	26	26	26				32.02	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											917.68	30						1199.63	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
H3219	003	0	1	04	01	H3219_003_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	003	0	1	04	01	H3219_003_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3219	003	0	1	04	01	H3219_003_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.81	25	25	25				88.13	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
H3219	003	0	1	04	01	H3219_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.80	35	35	35				30.59	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
H3219	003	0	1	04	01	H3219_003_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1161.16	33						850.16	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
H3219	004	0	1	04	01	H3219_004_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	004	0	1	04	01	H3219_004_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3219	004	0	1	04	01	H3219_004_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.09	25	25	25				83.87	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
H3219	004	0	1	04	01	H3219_004_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.06	35	35	35				32.82	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
H3219	004	0	1	04	01	H3219_004_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1380.19	33						1239.15	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
H3219	008	0	1	04	01	H3219_008_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	008	0	1	04	01	H3219_008_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	008	0	1	04	01	H3219_008_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.60	24	24	24				97.47	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
H3219	008	0	1	04	01	H3219_008_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.58	25	25	25				32.02	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
H3219	008	0	1	04	01	H3219_008_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											731.88	25						693.70	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
H3219	012	0	1	04	01	H3219_012_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	012	0	1	04	01	H3219_012_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	012	0	1	04	01	H3219_012_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											30.37	22	22	22				37.01	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	012	0	1	04	01	H3219_012_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.63	25	25	25				40.97	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
H3219	012	0	1	04	01	H3219_012_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											319.30	25						280.39	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
H3219	013	0	1	04	01	H3219_013_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	013	0	1	04	01	H3219_013_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3219	013	0	1	04	01	H3219_013_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.11	25	25	25				96.35	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
H3219	013	0	1	04	01	H3219_013_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.47	26	26	26				31.39	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	013	0	1	04	01	H3219_013_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											956.66	30						883.97	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
H3219	014	0	1	04	01	H3219_014_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3219	014	0	1	04	01	H3219_014_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3219	014	0	1	04	01	H3219_014_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.50	25	25	25				92.80	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
H3219	014	0	1	04	01	H3219_014_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.15	26	26	26				34.68	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	014	0	1	04	01	H3219_014_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											825.22	30						801.67	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
H3239	014	0	1	01	01	H3239_014_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	014	0	1	01	01	H3239_014_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	014	0	1	01	01	H3239_014_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.36	24	24	24				101.15	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
H3239	014	0	1	01	01	H3239_014_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.32	25	25	25				33.97	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
H3239	014	0	1	01	01	H3239_014_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											743.85	25						754.76	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
H3239	017	0	1	01	01	H3239_017_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	017	0	1	01	01	H3239_017_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	017	0	1	01	01	H3239_017_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.36	24	24	24				93.97	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
H3239	017	0	1	01	01	H3239_017_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.76	25	25	25				31.50	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
H3239	017	0	1	01	01	H3239_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											699.43	25						709.78	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
H3239	020	0	1	01	01	H3239_020_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	020	0	1	01	01	H3239_020_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	020	0	1	01	01	H3239_020_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.25	24	24	24				101.14	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
H3239	020	0	1	01	01	H3239_020_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.42	25	25	25				34.15	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
H3239	020	0	1	01	01	H3239_020_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											742.96	25						751.29	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
H3239	022	0	1	01	01	H3239_022_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	022	0	1	01	01	H3239_022_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3239	022	0	1	01	01	H3239_022_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.09	24	24	24				100.32	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
H3239	022	0	1	01	01	H3239_022_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.74	25	25	25				34.05	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
H3239	022	0	1	01	01	H3239_022_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											784.46	25						737.34	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
H3240	017	0	1	02	01	H3240_017_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																								
H3240	017	0	1	02	01	H3240_017_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H3240	017	0	1	02	01	H3240_017_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.24	25	25	25				70.31	20	20	20				20	20	20															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		35.00
H3240	017	0	1	02	01	H3240_017_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											91.99	25	25	25				91.99	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		35.00
H3240	017	0	1	02	01	H3240_017_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																								
H3240	017	0	1	02	01	H3240_017_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																								
H3240	022	0	1	02	01	H3240_022_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																								
H3240	022	0	1	02	01	H3240_022_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, Select Care Drugs																								
H3240	022	0	1	02	01	H3240_022_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.17	25	25	25				67.33	20	20	20				20	20	20															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	70.00				35.00		35.00
H3240	022	0	1	02	01	H3240_022_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											52.15	25	25	25				52.15	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		35.00
H3240	022	0	1	02	01	H3240_022_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																								
H3240	022	0	1	02	01	H3240_022_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																								
H3251	002	0	1	01	01	H3251_002_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3251	002	0	1	01	01	H3251_002_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3251	002	0	1	01	01	H3251_002_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	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.40	50	50	50				70.84	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
H3251	002	0	1	01	01	H3251_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											580.82	33						617.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3274	002	0	1	01	01	H3274_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																								
H3274	002	0	1	01	01	H3274_002_0	7			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	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
H3274	002	0	1	01	01	H3274_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										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	7			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	7			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	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																			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	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, 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	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, 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	7			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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H3274	005	0	1	01	01	H3274_005_0	6			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	005	0	1	01	01	H3274_005_0	6			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	005	0	1	01	01	H3274_005_0	6			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	005	0	1	01	01	H3274_005_0	6			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
H3274	005	0	1	01	01	H3274_005_0	6			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																								
H3288	001	0	1	04	01	H3288_001_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	001	0	1	04	01	H3288_001_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	001	0	1	04	01	H3288_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											70.93	24	24	24				95.52	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
H3288	001	0	1	04	01	H3288_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											49.25	25	25	25				43.67	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
H3288	001	0	1	04	01	H3288_001_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											816.07	25						995.42	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
H3288	002	0	1	04	01	H3288_002_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	002	0	1	04	01	H3288_002_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	002	0	1	04	01	H3288_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											77.91	24	24	24				97.71	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
H3288	002	0	1	04	01	H3288_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											50.65	25	25	25				42.63	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
H3288	002	0	1	04	01	H3288_002_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											801.64	25						741.52	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
H3288	003	0	1	04	01	H3288_003_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	003	0	1	04	01	H3288_003_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	003	0	1	04	01	H3288_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											80.89	24	24	24				107.86	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
H3288	003	0	1	04	01	H3288_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											44.78	25	25	25				38.19	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
H3288	003	0	1	04	01	H3288_003_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											906.88	25						732.48	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
H3288	004	0	1	04	01	H3288_004_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	004	0	1	04	01	H3288_004_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3288	004	0	1	04	01	H3288_004_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.37	25	25	25				76.49	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
H3288	004	0	1	04	01	H3288_004_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.22	35	35	35				39.60	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
H3288	004	0	1	04	01	H3288_004_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											879.50	33						924.38	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
H3288	005	0	1	04	01	H3288_005_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	005	0	1	04	01	H3288_005_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	005	0	1	04	01	H3288_005_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.73	24	24	24				114.77	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
H3288	005	0	1	04	01	H3288_005_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.73	25	25	25				34.37	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
H3288	005	0	1	04	01	H3288_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											965.05	25						739.90	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
H3288	006	0	1	04	01	H3288_006_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	006	0	1	04	01	H3288_006_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	006	0	1	04	01	H3288_006_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.86	22	22	22				44.44	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.63	25	25	25				48.93	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
H3288	006	0	1	04	01	H3288_006_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											333.46	25						302.30	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
H3288	007	0	1	04	01	H3288_007_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	007	0	1	04	01	H3288_007_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	007	0	1	04	01	H3288_007_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.54	22	22	22				46.65	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.45	25	25	25				53.28	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
H3288	007	0	1	04	01	H3288_007_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											347.87	25						301.55	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
H3288	008	0	1	04	01	H3288_008_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	008	0	1	04	01	H3288_008_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	008	0	1	04	01	H3288_008_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.11	22	22	22				45.76	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											51.78	25	25	25				49.24	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
H3288	008	0	1	04	01	H3288_008_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											367.73	25						315.98	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
H3288	009	0	1	04	01	H3288_009_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	009	0	1	04	01	H3288_009_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3288	009	0	1	04	01	H3288_009_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.42	25	25	25				122.92	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
H3288	009	0	1	04	01	H3288_009_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.51	26	26	26				38.45	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1088.03	30						952.33	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
H3288	011	0	1	04	01	H3288_011_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	011	0	1	04	01	H3288_011_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	011	0	1	04	01	H3288_011_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.89	22	22	22				43.84	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.54	25	25	25				45.44	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
H3288	011	0	1	04	01	H3288_011_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											334.07	25						299.99	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
H3288	016	0	1	04	01	H3288_016_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	016	0	1	04	01	H3288_016_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	016	0	1	04	01	H3288_016_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.25	22	22	22				44.59	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											51.04	25	25	25				46.94	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
H3288	016	0	1	04	01	H3288_016_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											327.41	25						303.50	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
H3288	017	0	1	04	01	H3288_017_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	017	0	1	04	01	H3288_017_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3288	017	0	1	04	01	H3288_017_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.18	25	25	25				80.87	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
H3288	017	0	1	04	01	H3288_017_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											42.98	35	35	35				34.05	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
H3288	017	0	1	04	01	H3288_017_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											887.86	33						1233.94	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	018	0	1	04	01	H3288_018_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	018	0	1	04	01	H3288_018_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3288	018	0	1	04	01	H3288_018_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.81	25	25	25				87.05	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
H3288	018	0	1	04	01	H3288_018_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											49.83	35	35	35				39.03	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
H3288	018	0	1	04	01	H3288_018_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1259.69	33						941.67	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
H3288	019	0	1	04	01	H3288_019_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	019	0	1	04	01	H3288_019_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3288	019	0	1	04	01	H3288_019_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.02	25	25	25				81.12	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
H3288	019	0	1	04	01	H3288_019_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											45.52	35	35	35				35.68	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
H3288	019	0	1	04	01	H3288_019_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											960.29	33						807.87	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
H3288	020	0	1	04	01	H3288_020_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	020	0	1	04	01	H3288_020_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3288	020	0	1	04	01	H3288_020_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.31	25	25	25				102.00	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
H3288	020	0	1	04	01	H3288_020_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.41	26	26	26				33.04	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											975.06	30						1033.36	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
H3288	021	0	1	04	01	H3288_021_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	021	0	1	04	01	H3288_021_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3288	021	0	1	04	01	H3288_021_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.61	25	25	25				99.65	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
H3288	021	0	1	04	01	H3288_021_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.68	26	26	26				37.19	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											910.75	30						869.15	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
H3288	027	0	1	04	01	H3288_027_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
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								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																								
H3288	027	0	1	04	01	H3288_027_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.86	24	24	24				105.74	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
H3288	027	0	1	04	01	H3288_027_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											41.29	25	25	25				34.41	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
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											1315.09	25						673.40	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
H3288	031	0	1	04	01	H3288_031_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
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								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																								
H3288	031	0	1	04	01	H3288_031_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.82	24	24	24				108.10	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
H3288	031	0	1	04	01	H3288_031_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											40.83	25	25	25				37.96	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
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											982.01	25						744.30	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
H3288	042	0	1	04	01	H3288_042_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
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								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																								
H3288	042	0	1	04	01	H3288_042_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.64	24	24	24				103.27	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
H3288	042	0	1	04	01	H3288_042_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											46.13	25	25	25				37.43	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
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											866.42	25						695.39	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
H3288	046	0	1	04	01	H3288_046_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	046	0	1	04	01	H3288_046_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	046	0	1	04	01	H3288_046_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.46	22	22	22				45.55	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.12	25	25	25				50.72	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
H3288	046	0	1	04	01	H3288_046_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											322.43	25						293.02	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
H3288	047	0	1	04	01	H3288_047_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	047	0	1	04	01	H3288_047_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	047	0	1	04	01	H3288_047_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.10	24	24	24				116.98	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
H3288	047	0	1	04	01	H3288_047_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.74	25	25	25				39.02	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
H3288	047	0	1	04	01	H3288_047_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											883.14	25						752.78	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
H3288	048	0	1	04	01	H3288_048_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	048	0	1	04	01	H3288_048_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3288	048	0	1	04	01	H3288_048_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.59	24	24	24				100.01	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
H3288	048	0	1	04	01	H3288_048_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											49.76	25	25	25				38.55	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
H3288	048	0	1	04	01	H3288_048_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.67	25						874.47	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
H3291	003	0	1	01	01	H3291_003_0	6			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																								
H3291	003	0	1	01	01	H3291_003_0	6			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	7.00	14.00	21.00																			7.00	14.00	21.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H3291	003	0	1	01	01	H3291_003_0	6			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
H3291	003	0	1	01	01	H3291_003_0	6			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
H3291	003	0	1	01	01	H3291_003_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31					33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H3305	015	0	1	02	01	H3305_015_0	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H3305	015	0	1	02	01	H3305_015_0	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				94.06	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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				468.31	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	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H3305	022	0	1	02	01	H3305_022_0	7			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	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																			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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				79.78	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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				382.34	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	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H3305	030	0	1	02	01	H3305_030_0	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				118.22	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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				826.61	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H3312	002	0	1	01	01	H3312_002_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	002	0	1	01	01	H3312_002_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	002	0	1	01	01	H3312_002_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											116.80	24	24	24				120.02	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
H3312	002	0	1	01	01	H3312_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.86	25	25	25				50.05	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
H3312	002	0	1	01	01	H3312_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											685.62	25						858.13	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
H3312	018	0	1	01	01	H3312_018_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	018	0	1	01	01	H3312_018_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	018	0	1	01	01	H3312_018_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.87	22	22	22				109.80	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.99	25	25	25				40.00	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
H3312	018	0	1	01	01	H3312_018_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											725.39	27						915.41	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
H3312	048	0	1	02	01	H3312_048_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	048	0	1	02	01	H3312_048_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	048	0	1	02	01	H3312_048_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.58	22	22	22				105.23	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	02	01	H3312_048_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.38	25	25	25				34.32	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
H3312	048	0	1	02	01	H3312_048_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1000.16	27						881.84	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
H3312	062	0	1	02	01	H3312_062_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	062	0	1	02	01	H3312_062_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	062	0	1	02	01	H3312_062_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.32	24	24	24				116.86	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
H3312	062	0	1	02	01	H3312_062_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											51.23	25	25	25				39.98	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
H3312	062	0	1	02	01	H3312_062_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											742.06	25						797.70	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
H3312	064	0	1	01	01	H3312_064_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	064	0	1	01	01	H3312_064_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	064	0	1	01	01	H3312_064_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.75	24	24	24				116.53	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
H3312	064	0	1	01	01	H3312_064_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.19	25	25	25				42.27	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
H3312	064	0	1	01	01	H3312_064_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											814.07	25						841.13	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
H3312	065	0	1	02	01	H3312_065_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	065	0	1	02	01	H3312_065_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3312	065	0	1	02	01	H3312_065_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.58	25	25	25				96.38	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
H3312	065	0	1	02	01	H3312_065_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.76	35	35	35				34.91	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
H3312	065	0	1	02	01	H3312_065_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1009.10	33						1232.75	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
H3312	074	0	1	01	01	H3312_074_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	074	0	1	01	01	H3312_074_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	074	0	1	01	01	H3312_074_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.49	24	24	24				124.72	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
H3312	074	0	1	01	01	H3312_074_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.51	25	25	25				40.36	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
H3312	074	0	1	01	01	H3312_074_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											923.26	25						893.28	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
H3312	079	0	1	01	01	H3312_079_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	079	0	1	01	01	H3312_079_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	079	0	1	01	01	H3312_079_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.91	22	22	22				47.06	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	079	0	1	01	01	H3312_079_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.32	25	25	25				50.92	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
H3312	079	0	1	01	01	H3312_079_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											409.23	25						365.05	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
H3312	081	0	1	01	01	H3312_081_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	081	0	1	01	01	H3312_081_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	081	0	1	01	01	H3312_081_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.91	22	22	22				47.06	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	081	0	1	01	01	H3312_081_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.32	25	25	25				50.92	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
H3312	081	0	1	01	01	H3312_081_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											409.23	25						365.02	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
H3312	082	0	1	01	01	H3312_082_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	082	0	1	01	01	H3312_082_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3312	082	0	1	01	01	H3312_082_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.91	22	22	22				47.06	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	082	0	1	01	01	H3312_082_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.32	25	25	25				50.92	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
H3312	082	0	1	01	01	H3312_082_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											409.23	25						365.03	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
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	2	1	01	01	H3330_021_2	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	2	1	01	01	H3330_021_2	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	2	1	01	01	H3330_021_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					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	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	2	1	01	01	H3330_021_2	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	2	1	01	01	H3330_021_2	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	3	1	01	01	H3330_021_3	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	3	1	01	01	H3330_021_3	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	3	1	01	01	H3330_021_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					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	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	3	1	01	01	H3330_021_3	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	3	1	01	01	H3330_021_3	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	5	1	01	01	H3330_021_5	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	5	1	01	01	H3330_021_5	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	5	1	01	01	H3330_021_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					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	5	1	01	01	H3330_021_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					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	5	1	01	01	H3330_021_5	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	5	1	01	01	H3330_021_5	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	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	038	0	1	01	01	H3330_038_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					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	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	038	0	1	01	01	H3330_038_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	038	0	1	01	01	H3330_038_0	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	038	0	1	01	01	H3330_038_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			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																								
H3335	015	0	1	04	01	H3335_015_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	015	0	1	04	01	H3335_015_0	6			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	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	015	0	1	04	01	H3335_015_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											51.00	50	50	50				55.00	50	50	50										50	50	50				50	50	50			50			50								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	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
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								5.00	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										5.00	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
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								11.00	22.00	33.00					6.00	12.00	18.00											11.00	22.00	33.00				6.00	12.00	18.00				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	33.00	6.00	12.00	18.00	11.00	22.00	33.00	6.00	12.00	18.00	11.00		6.00
H3335	018	0	1	04	01	H3335_018_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.00	25	25	25				65.00	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	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											42.00	25	25	25				44.00	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	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	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	038	0	1	04	01	H3335_038_0	6			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	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	038	0	1	04	01	H3335_038_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											57.00	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										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	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										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	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.00	50	50	50				74.00	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	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	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
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											90.00	50	50	50				92.00	45	45	45										50	50	50				45	45	45			50			45								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	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										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	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											76.00	50	50	50				79.00	50	50	50										50	50	50				50	50	50			50			50								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	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
H3335	058	0	1	04	01	H3335_058_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	058	0	1	04	01	H3335_058_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	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	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	058	0	1	04	01	H3335_058_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											73.00	50	50	50				79.00	50	50	50										50	50	50				50	50	50			50			50								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	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	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
H3335	059	0	1	04	01	H3335_059_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	20.00					0.00	0.00	0.00											10.00	20.00	20.00				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										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		0.00
H3335	059	0	1	04	01	H3335_059_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	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
H3335	059	0	1	04	01	H3335_059_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	35.00	70.00	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3335	059	0	1	04	01	H3335_059_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											91.00	50	50	50				91.00	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	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3335	059	0	1	04	01	H3335_059_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	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	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3335	060	0	1	04	01	H3335_060_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	060	0	1	04	01	H3335_060_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	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
H3335	060	0	1	04	01	H3335_060_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	35.00	70.00	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3335	060	0	1	04	01	H3335_060_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	35.00	70.00	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3335	060	0	1	04	01	H3335_060_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	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	35.00	70.00	70.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3342	023	1	1	04	01	H3342_023_1	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																								
H3342	023	1	1	04	01	H3342_023_1	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					2.00	4.00	6.00					2.00	6.00	6.00																7.00				7.00			0.23	0.07	0.07			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3342	023	1	1	04	01	H3342_023_1	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.05	20	20	20				65.05	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		35.00
H3342	023	1	1	04	01	H3342_023_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.00	35	35	35				58.00	35	35	35				35	35	35															35			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
H3342	023	1	1	04	01	H3342_023_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, Select Care Drugs																								
H3342	023	1	1	04	01	H3342_023_1	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																								
H3342	023	2	1	04	01	H3342_023_2	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																								
H3342	023	2	1	04	01	H3342_023_2	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					2.00	4.00	6.00					2.00	6.00	6.00																7.00				7.00			0.23	0.07	0.07			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3342	023	2	1	04	01	H3342_023_2	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.05	20	20	20				65.05	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		35.00
H3342	023	2	1	04	01	H3342_023_2	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.00	35	35	35				58.00	35	35	35				35	35	35															35			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
H3342	023	2	1	04	01	H3342_023_2	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, Select Care Drugs																								
H3342	023	2	1	04	01	H3342_023_2	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																								
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	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
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				70.19	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	012	0	1	04	01	H3344_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				361.37	27																																					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3344	013	0	1	04	01	H3344_013_0	5			Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				1	2			100				30		34					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		85.00						85.00				34.00		34.00
H3344	013	0	1	04	01	H3344_013_0	5			Generic	4	01	3	1	2	1	110		01	100		1	30		90				2	2			90				30		34					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
H3344	013	0	1	04	01	H3344_013_0	5			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				2	2			90				30		34					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
H3344	013	0	1	04	01	H3344_013_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34					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
H3344	013	0	1	04	01	H3344_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3347	009	0	1	02	01	H3347_009_0	6			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	6			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	6			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	6			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	6			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				1045.52	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	6			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	6			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	6			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	6			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	6			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				1222.17	28	28	28																				28															28			28								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	5			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	018	0	1	02	01	H3347_018_0	5			Generic	4	11	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	2.00	4.00	6.00																					4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2.00	4.00	6.00						4.00				2.00		2.00
H3347	018	0	1	02	01	H3347_018_0	5			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	25.00	50.00	75.00																					50.00																25.00				25.00		0.83						0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00	50.00	75.00						50.00				25.00		25.00
H3347	018	0	1	02	01	H3347_018_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																					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	018	0	1	02	01	H3347_018_0	5			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				1007.66	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	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
H3351	002	0	1	02	01	H3351_002_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	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	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
H3351	002	0	1	02	01	H3351_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											48.00	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										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	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
H3351	006	0	1	02	01	H3351_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								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	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	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	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
H3351	006	0	1	02	01	H3351_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											53.00	50	50	50				54.00	50	50	50										50	50	50				50	50	50			50			50								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	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
H3351	012	0	1	02	01	H3351_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								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	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
H3351	012	0	1	02	01	H3351_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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.00	50	50	50				55.00	50	50	50										50	50	50				50	50	50			50			50								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	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
H3351	013	0	1	02	01	H3351_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								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	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	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	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
H3351	013	0	1	02	01	H3351_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											54.00	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										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	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
H3351	016	0	1	01	01	H3351_016_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
H3351	016	0	1	01	01	H3351_016_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	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	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
H3351	016	0	1	01	01	H3351_016_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											79.00	50	50	50				77.00	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	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	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	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										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	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
H3351	017	0	1	01	01	H3351_017_0	5			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	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
H3351	017	0	1	01	01	H3351_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											72.00	50	50	50				80.00	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	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	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
H3351	018	0	1	02	01	H3351_018_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
H3351	018	0	1	02	01	H3351_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	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	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
H3351	018	0	1	02	01	H3351_018_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											83.00	50	50	50				81.00	50	50	50										50	50	50				50	50	50			50			50								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	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	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
H3351	019	0	1	02	01	H3351_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								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	5			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	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
H3351	019	0	1	02	01	H3351_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											68.00	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										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	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	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											78.00	50	50	50				86.00	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	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	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										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	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
H3351	021	0	1	01	01	H3351_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	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	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
H3351	021	0	1	01	01	H3351_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											78.00	50	50	50				94.00	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	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	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	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										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	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										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	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	15.00																			15.00	30.00	15.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	30.00	15.00				15.00	30.00	15.00				15.00		15.00
H3359	001	0	1	01	01	H3359_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	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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				49.28	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
H3359	001	0	1	01	01	H3359_001_0	7			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
H3359	019	0	1	01	01	H3359_019_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
H3359	019	0	1	01	01	H3359_019_0	9			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	019	0	1	01	01	H3359_019_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										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	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				57.92	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	019	0	1	01	01	H3359_019_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										35.00						35.00						35.00		35.00
H3359	021	0	1	01	01	H3359_021_0	10		N	Preferred Generic	4	11	1	2	1	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	021	0	1	01	01	H3359_021_0	10		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				2.85	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		35.00
H3359	021	0	1	01	01	H3359_021_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				44.27	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		35.00
H3359	021	0	1	01	01	H3359_021_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				35.63	26	26	26																		26	26	26															26			26								Preferred Generic, 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	021	0	1	01	01	H3359_021_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										35.00						35.00						35.00		35.00
H3359	034	0	1	01	01	H3359_034_0	10		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										5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H3359	034	0	1	01	01	H3359_034_0	10		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				2.77	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		35.00
H3359	034	0	1	01	01	H3359_034_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				38.23	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		35.00
H3359	034	0	1	01	01	H3359_034_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				34.33	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	034	0	1	01	01	H3359_034_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										35.00						35.00						35.00		35.00
H3359	038	0	1	01	01	H3359_038_0	8		N	Preferred Generic	4	11	1	2	1	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	8		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				3.18	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		35.00
H3359	038	0	1	01	01	H3359_038_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				48.66	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	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				37.98	26	26	26																		26	26	26															26			26								Preferred Generic, 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	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										35.00						35.00						35.00		35.00
H3362	017	0	1	01	01	H3362_017_0	6			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	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	13.00		32.50																					32.50																13.00				13.00		0.43						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00		32.50						32.50				13.00		13.00
H3362	017	0	1	01	01	H3362_017_0	6			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	6			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				83.38	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	017	0	1	01	01	H3362_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				454.18	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3362	020	0	1	01	01	H3362_020_0	6			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		0.1						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										3.00		7.50						7.50				3.00		3.00
H3362	020	0	1	01	01	H3362_020_0	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	13.00		32.50																					32.50																13.00				13.00		0.43						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00		32.50						32.50				13.00		13.00
H3362	020	0	1	01	01	H3362_020_0	6			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				2	2			90				30		34				54.39	19		19																				19															19			19								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	6			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				78.12	37		37																				37															37			37								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	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				366.06	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3362	033	0	1	01	01	H3362_033_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	033	0	1	01	01	H3362_033_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		0.5						0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00		37.50						37.50				15.00		15.00
H3362	033	0	1	01	01	H3362_033_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		1.4						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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				77.86	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	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				404.64	28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3362	040	0	1	01	01	H3362_040_0	6			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	6			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		0.4						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	6			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	6			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				89.81	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	040	0	1	01	01	H3362_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				411.49	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3362	041	0	1	01	01	H3362_041_0	5			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	041	0	1	01	01	H3362_041_0	5			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	041	0	1	01	01	H3362_041_0	5			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	041	0	1	01	01	H3362_041_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				89.63	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	041	0	1	01	01	H3362_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				458.80	27																																					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3379	001	0	1	02	01	H3379_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																								
H3379	001	0	1	02	01	H3379_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																								
H3379	001	0	1	02	01	H3379_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
H3379	001	0	1	02	01	H3379_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3379	001	0	1	02	01	H3379_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				175.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				175.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				185.00	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
H3379	043	0	1	02	01	H3379_043_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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																								
H3379	043	0	1	02	01	H3379_043_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	043	0	1	02	01	H3379_043_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3379	043	0	1	02	01	H3379_043_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				206.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				169.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				171.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				170.00	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
H3379	052	0	1	02	01	H3379_052_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	052	0	1	02	01	H3379_052_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	052	0	1	02	01	H3379_052_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	052	0	1	02	01	H3379_052_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3379	052	0	1	02	01	H3379_052_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
H3379	053	0	1	02	01	H3379_053_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	053	0	1	02	01	H3379_053_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																								
H3379	053	0	1	02	01	H3379_053_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
H3379	053	0	1	02	01	H3379_053_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3379	053	0	1	02	01	H3379_053_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				197.00	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
H3379	054	0	1	02	01	H3379_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																								
H3379	054	0	1	02	01	H3379_054_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	054	0	1	02	01	H3379_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										25.00		75.00						75.00			65.00	25.00		25.00
H3379	054	0	1	02	01	H3379_054_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3379	054	0	1	02	01	H3379_054_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				198.00	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
H3379	056	0	1	02	01	H3379_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																								
H3379	056	0	1	02	01	H3379_056_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	056	0	1	02	01	H3379_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										25.00		75.00						75.00			65.00	25.00		25.00
H3379	056	0	1	02	01	H3379_056_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3379	056	0	1	02	01	H3379_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				198.00	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
H3384	013	0	1	01	01	H3384_013_0	5			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													17.50						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	013	0	1	01	01	H3384_013_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					10.00		30.00													37.50						25.00				15.00				15.00			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	5			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													117.50						105.00				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
H3384	013	0	1	01	01	H3384_013_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					94.00		282.00													250.00						235.00				100.00				100.00			3.23	3.03				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
H3384	013	0	1	01	01	H3384_013_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	019	0	1	01	01	H3384_019_0	5			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													17.50						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	019	0	1	01	01	H3384_019_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					10.00		30.00													37.50						25.00				15.00				15.00			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	5			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													117.50						105.00				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
H3384	019	0	1	01	01	H3384_019_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					94.00		282.00													250.00						235.00				100.00				100.00			3.23	3.03				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
H3384	019	0	1	01	01	H3384_019_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	058	0	1	01	01	H3384_058_0	5			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													17.50						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	058	0	1	01	01	H3384_058_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					10.00		30.00													37.50						25.00				15.00				15.00			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											98.20	25		25				102.67	25		25												25						25			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
H3384	058	0	1	01	01	H3384_058_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.52	40		40				42.68	40		40												40						40			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
H3384	058	0	1	01	01	H3384_058_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	059	0	1	01	01	H3384_059_0	6			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													17.50						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	059	0	1	01	01	H3384_059_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								13.00		39.00					8.00		24.00													32.50						20.00				13.00				13.00			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.91	25		25				97.62	25		25												25						25			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
H3384	059	0	1	01	01	H3384_059_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											58.09	50		50				48.06	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
H3384	059	0	1	01	01	H3384_059_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											0.00	33						0.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	062	0	1	01	01	H3384_062_0	5			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													12.50						0.00				5.00				5.00			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	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								17.00		51.00					2.00		6.00													42.50						0.00				17.00				17.00			0.55	0.06				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	062	0	1	01	01	H3384_062_0	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											103.44	25		25				108.58	25		25												25						25			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
H3384	062	0	1	01	01	H3384_062_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											60.13	50		50				45.11	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
H3384	062	0	1	01	01	H3384_062_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	067	0	1	01	01	H3384_067_0	5			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													17.50						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3384	067	0	1	01	01	H3384_067_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								17.00		51.00					12.00		36.00													42.50						30.00				17.00				17.00			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											109.84	25		25				108.40	25		25												25						25			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
H3384	067	0	1	01	01	H3384_067_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											45.51	33		33				30.46	33		33												33						33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3384	067	0	1	01	01	H3384_067_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3388	002	0	1	01	01	H3388_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								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	8			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	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					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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.17	40	40	40				98.17	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	70.00	35.00		35.00
H3388	002	0	1	01	01	H3388_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1588.16	33						1588.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3388	004	0	1	01	01	H3388_004_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					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	8			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	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					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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.32	39	39	39				98.32	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	70.00	35.00		35.00
H3388	004	0	1	01	01	H3388_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1662.83	33						1662.83	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3388	014	0	1	01	01	H3388_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								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	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					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	0.67	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3388	014	0	1	01	01	H3388_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								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	1.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											97.92	39	39	39				97.92	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	70.00	35.00		35.00
H3388	014	0	1	01	01	H3388_014_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1399.46	30						1399.46	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3404	003	1	1	04	01	H3404_003_1	17			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	17			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	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					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	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					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	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																								
H3404	003	1	1	04	01	H3404_003_1	17			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	17			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	17			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	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					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	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					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	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																								
H3404	003	2	1	04	01	H3404_003_2	17			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																								
H3418	001	0	1	04	01	H3418_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																								
H3418	001	0	1	04	01	H3418_001_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																								
H3418	001	0	1	04	01	H3418_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
H3418	001	0	1	04	01	H3418_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3418	001	0	1	04	01	H3418_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				212.00	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
H3418	002	0	1	04	01	H3418_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																								
H3418	002	0	1	04	01	H3418_002_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																								
H3418	002	0	1	04	01	H3418_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
H3418	002	0	1	04	01	H3418_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3418	002	0	1	04	01	H3418_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				178.00	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
H3418	004	0	1	04	01	H3418_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																								
H3418	004	0	1	04	01	H3418_004_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																								
H3418	004	0	1	04	01	H3418_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
H3418	004	0	1	04	01	H3418_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3418	004	0	1	04	01	H3418_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				160.00	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
H3418	007	0	1	04	01	H3418_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																								
H3418	007	0	1	04	01	H3418_007_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																								
H3418	007	0	1	04	01	H3418_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
H3418	007	0	1	04	01	H3418_007_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3418	007	0	1	04	01	H3418_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
H3418	008	0	1	04	01	H3418_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																								
H3418	008	0	1	04	01	H3418_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																								
H3418	008	0	1	04	01	H3418_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
H3418	008	0	1	04	01	H3418_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3418	008	0	1	04	01	H3418_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H3418	009	0	1	04	01	H3418_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																								
H3418	009	0	1	04	01	H3418_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																								
H3418	009	0	1	04	01	H3418_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
H3418	009	0	1	04	01	H3418_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3418	009	0	1	04	01	H3418_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				190.00	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
H3418	010	0	1	04	01	H3418_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																								
H3418	010	0	1	04	01	H3418_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																								
H3418	010	0	1	04	01	H3418_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
H3418	010	0	1	04	01	H3418_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3418	010	0	1	04	01	H3418_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
H3419	003	0	1	02	01	H3419_003_0	6			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	02	01	H3419_003_0	6			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																								
H3419	003	0	1	02	01	H3419_003_0	6			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	02	01	H3419_003_0	6			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
H3419	003	0	1	02	01	H3419_003_0	6			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	02	01	H3419_004_0	6			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	02	01	H3419_004_0	6			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																								
H3419	004	0	1	02	01	H3419_004_0	6			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	02	01	H3419_004_0	6			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
H3419	004	0	1	02	01	H3419_004_0	6			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	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
H3443	001	0	1	01	01	H3443_001_0	9			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
H3443	001	0	1	01	01	H3443_001_0	9			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	001	0	1	01	01	H3443_001_0	9			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	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				576.02	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	9			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	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
H3443	002	0	1	01	01	H3443_002_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	Preferred 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	9			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	9			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	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				618.01	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	9			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	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
H3443	003	0	1	01	01	H3443_003_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										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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				421.41	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	8			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	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
H3443	005	0	1	01	01	H3443_005_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										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	8			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
H3443	005	0	1	01	01	H3443_005_0	8			Non-Preferred Drug	4	11	3	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, 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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				431.34	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	8			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	0.00																			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																								
H3447	013	0	1	02	01	H3447_013_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																								
H3447	013	0	1	02	01	H3447_013_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H3447	013	0	1	02	01	H3447_013_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.95	20	20	20				58.95	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	70.00				35.00		35.00
H3447	013	0	1	02	01	H3447_013_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											51.94	35	35	35				51.94	35	35	35				35	35	35															35			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
H3447	013	0	1	02	01	H3447_013_0	9			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																								
H3447	013	0	1	02	01	H3447_013_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3447	024	0	1	02	01	H3447_024_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																								
H3447	024	0	1	02	01	H3447_024_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				12.49	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3447	024	0	1	02	01	H3447_024_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				68.07	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
H3447	024	0	1	02	01	H3447_024_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				39.23	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
H3447	024	0	1	02	01	H3447_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3447	024	0	1	02	01	H3447_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		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	025	0	1	02	01	H3447_025_0	8			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	025	0	1	02	01	H3447_025_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H3447	025	0	1	02	01	H3447_025_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											60.51	20	20	20				60.51	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	70.00				35.00		35.00
H3447	025	0	1	02	01	H3447_025_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											48.49	35	35	35				48.49	35	35	35				35	35	35															35			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
H3447	025	0	1	02	01	H3447_025_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																								
H3447	025	0	1	02	01	H3447_025_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																								
H3447	028	0	1	02	01	H3447_028_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																								
H3447	028	0	1	02	01	H3447_028_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				13.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3447	028	0	1	02	01	H3447_028_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				72.68	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
H3447	028	0	1	02	01	H3447_028_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				38.71	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
H3447	028	0	1	02	01	H3447_028_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3447	028	0	1	02	01	H3447_028_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																								
H3447	033	0	1	02	01	H3447_033_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	033	0	1	02	01	H3447_033_0	7			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					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	033	0	1	02	01	H3447_033_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.40	25	25	25				51.52	20	20	20				20	20	20															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		35.00
H3447	033	0	1	02	01	H3447_033_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											77.47	25	25	25				77.47	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		35.00
H3447	033	0	1	02	01	H3447_033_0	7			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																								
H3447	033	0	1	02	01	H3447_033_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																								
H3447	037	0	1	02	01	H3447_037_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																								
H3447	037	0	1	02	01	H3447_037_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																								
H3447	037	0	1	02	01	H3447_037_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											116.25	25	25	25				93.00	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	037	0	1	02	01	H3447_037_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											45.35	25	25	25				45.35	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		35.00
H3447	037	0	1	02	01	H3447_037_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	037	0	1	02	01	H3447_037_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	038	1	1	02	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	02	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	02	01	H3447_038_1	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											49.25	25	25	25				39.40	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	038	1	1	02	01	H3447_038_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											40.50	40	40	40				40.50	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		35.00
H3447	038	1	1	02	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	02	01	H3447_038_1	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																								
H3447	038	2	1	02	01	H3447_038_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																								
H3447	038	2	1	02	01	H3447_038_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																								
H3447	038	2	1	02	01	H3447_038_2	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											49.25	25	25	25				39.40	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	038	2	1	02	01	H3447_038_2	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											40.50	40	40	40				40.50	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		35.00
H3447	038	2	1	02	01	H3447_038_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																								
H3447	038	2	1	02	01	H3447_038_2	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																								
H3447	039	0	1	02	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	02	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								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																								
H3447	039	0	1	02	01	H3447_039_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.92	20	20	20				58.92	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	70.00				35.00		35.00
H3447	039	0	1	02	01	H3447_039_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											46.25	35	35	35				46.25	35	35	35				35	35	35															35			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
H3447	039	0	1	02	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	02	01	H3447_039_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																								
H3447	042	1	1	02	01	H3447_042_1	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																								
H3447	042	1	1	02	01	H3447_042_1	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																								
H3447	042	1	1	02	01	H3447_042_1	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.41	25	25	25				41.92	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	042	1	1	02	01	H3447_042_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.14	45	45	45				50.14	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		35.00
H3447	042	1	1	02	01	H3447_042_1	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	042	1	1	02	01	H3447_042_1	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																								
H3447	042	2	1	02	01	H3447_042_2	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																								
H3447	042	2	1	02	01	H3447_042_2	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																								
H3447	042	2	1	02	01	H3447_042_2	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.41	25	25	25				41.92	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	042	2	1	02	01	H3447_042_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.14	45	45	45				50.14	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		35.00
H3447	042	2	1	02	01	H3447_042_2	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	042	2	1	02	01	H3447_042_2	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																								
H3447	042	3	1	02	01	H3447_042_3	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																								
H3447	042	3	1	02	01	H3447_042_3	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																								
H3447	042	3	1	02	01	H3447_042_3	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.41	25	25	25				41.92	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	042	3	1	02	01	H3447_042_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.14	45	45	45				50.14	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		35.00
H3447	042	3	1	02	01	H3447_042_3	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	042	3	1	02	01	H3447_042_3	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																								
H3447	042	4	1	02	01	H3447_042_4	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																								
H3447	042	4	1	02	01	H3447_042_4	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																								
H3447	042	4	1	02	01	H3447_042_4	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.41	25	25	25				41.92	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	042	4	1	02	01	H3447_042_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.14	45	45	45				50.14	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		35.00
H3447	042	4	1	02	01	H3447_042_4	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	042	4	1	02	01	H3447_042_4	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																								
H3447	043	0	1	02	01	H3447_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	02	01	H3447_043_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																								
H3447	043	0	1	02	01	H3447_043_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.26	25	25	25				52.21	20	20	20				20	20	20															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	70.00				35.00		35.00
H3447	043	0	1	02	01	H3447_043_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											57.09	45	45	45				57.09	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		35.00
H3447	043	0	1	02	01	H3447_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																								
H3447	043	0	1	02	01	H3447_043_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																								
H3447	049	0	1	02	01	H3447_049_0	7			Preferred Generic	4	11	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																								
H3447	049	0	1	02	01	H3447_049_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																								
H3447	049	0	1	02	01	H3447_049_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											95.65	20	20	20				95.65	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
H3447	049	0	1	02	01	H3447_049_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											25.02	35	35	35				25.02	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		35.00
H3447	049	0	1	02	01	H3447_049_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																								
H3447	050	0	1	02	01	H3447_050_0	8			Preferred Generic	4	11	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																								
H3447	050	0	1	02	01	H3447_050_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																								
H3447	050	0	1	02	01	H3447_050_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											94.65	20	20	20				94.65	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
H3447	050	0	1	02	01	H3447_050_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											24.91	35	35	35				24.91	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		35.00
H3447	050	0	1	02	01	H3447_050_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																								
H3447	051	0	1	02	01	H3447_051_0	7			Preferred Generic	4	11	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																								
H3447	051	0	1	02	01	H3447_051_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																								
H3447	051	0	1	02	01	H3447_051_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											111.98	20	20	20				111.98	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
H3447	051	0	1	02	01	H3447_051_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											30.21	35	35	35				30.21	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		35.00
H3447	051	0	1	02	01	H3447_051_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																								
H3447	052	0	1	02	01	H3447_052_0	7			Preferred Generic	4	11	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																								
H3447	052	0	1	02	01	H3447_052_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H3447	052	0	1	02	01	H3447_052_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											94.32	20	20	20				94.32	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
H3447	052	0	1	02	01	H3447_052_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											25.58	35	35	35				25.58	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		35.00
H3447	052	0	1	02	01	H3447_052_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																								
H3447	054	0	1	02	01	H3447_054_0	6			Preferred Generic	4	11	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																								
H3447	054	0	1	02	01	H3447_054_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																								
H3447	054	0	1	02	01	H3447_054_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											92.52	25	25	25				74.02	20	20	20				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	70.00				35.00		35.00
H3447	054	0	1	02	01	H3447_054_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											22.93	40	40	40				22.93	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
H3447	054	0	1	02	01	H3447_054_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																								
H3449	023	1	1	02	01	H3449_023_1	16			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	16			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	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					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	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.63	49	49	49				95.18	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
H3449	023	1	1	02	01	H3449_023_1	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																								
H3449	023	1	1	02	01	H3449_023_1	16			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	16			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	16			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	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					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	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.63	49	49	49				95.18	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
H3449	023	2	1	02	01	H3449_023_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																								
H3449	023	2	1	02	01	H3449_023_2	16			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	16			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	16			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	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					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	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.63	49	49	49				95.18	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
H3449	023	4	1	02	01	H3449_023_4	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																								
H3449	023	4	1	02	01	H3449_023_4	16			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	16			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	16			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	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					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	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.63	49	49	49				95.18	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
H3449	023	5	1	02	01	H3449_023_5	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																								
H3449	023	5	1	02	01	H3449_023_5	16			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	024	1	1	02	01	H3449_024_1	15			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	15			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	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	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	15			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	15			Specialty Tier	4	11	1	1	5	1		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	024	1	1	02	01	H3449_024_1	15			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	15			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	15			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	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	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	15			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	15			Specialty Tier	4	11	1	1	5	1		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	024	2	1	02	01	H3449_024_2	15			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	15			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	15			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	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	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	15			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	15			Specialty Tier	4	11	1	1	5	1		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	024	3	1	02	01	H3449_024_3	15			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	026	0	1	01	01	H3449_026_0	15			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	15			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	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	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	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.64	44	44	44				95.03	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
H3449	026	0	1	01	01	H3449_026_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																								
H3449	026	0	1	01	01	H3449_026_0	15			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	16			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	16			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	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					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	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											91.26	49	49	49				91.95	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
H3449	027	1	1	01	01	H3449_027_1	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																								
H3449	027	1	1	01	01	H3449_027_1	16			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	16			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	16			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	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					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	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											91.26	49	49	49				91.95	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
H3449	027	2	1	01	01	H3449_027_2	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																								
H3449	027	2	1	01	01	H3449_027_2	16			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																								
H3467	005	0	1	02	01	H3467_005_0	8			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																								
H3467	005	0	1	02	01	H3467_005_0	8			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	7.00	14.00	21.00																			7.00	14.00	21.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H3467	005	0	1	02	01	H3467_005_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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3467	005	0	1	02	01	H3467_005_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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3467	005	0	1	02	01	H3467_005_0	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31					29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H3499	002	0	1	01	01	H3499_002_0	5			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	5			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																								
H3499	002	0	1	01	01	H3499_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											162.73	25	25	25				162.73	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
H3499	002	0	1	01	01	H3499_002_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											52.34	44	44	44				52.34	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
H3499	002	0	1	01	01	H3499_002_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, Select Care Drugs																								
H3499	002	0	1	01	01	H3499_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3499	008	0	1	01	01	H3499_008_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3499	008	0	1	01	01	H3499_008_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3499	008	0	1	01	01	H3499_008_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											131.52	22	22	22				131.52	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
H3499	008	0	1	01	01	H3499_008_0	5			Non-Preferred Drug	3	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	200.00				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
H3499	008	0	1	01	01	H3499_008_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																								
H3499	008	0	1	01	01	H3499_008_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																								
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	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	011	1	1	02	01	H3528_011_1	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	011	1	1	02	01	H3528_011_1	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	011	1	1	02	01	H3528_011_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	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	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	011	1	1	02	01	H3528_011_1	12			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	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	011	2	1	02	01	H3528_011_2	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	011	2	1	02	01	H3528_011_2	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	011	2	1	02	01	H3528_011_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	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	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	011	2	1	02	01	H3528_011_2	12			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	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			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	015	0	1	02	01	H3528_015_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	015	0	1	02	01	H3528_015_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	015	0	1	02	01	H3528_015_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	015	0	1	02	01	H3528_015_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	015	0	1	02	01	H3528_015_0	12			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	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	016	0	1	02	01	H3528_016_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	016	0	1	02	01	H3528_016_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	016	0	1	02	01	H3528_016_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	016	0	1	02	01	H3528_016_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	016	0	1	02	01	H3528_016_0	12			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	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																								
H3533	027	0	1	01	01	H3533_027_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
H3533	027	0	1	01	01	H3533_027_0	4			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	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		95.00	35.00		35.00
H3533	027	0	1	01	01	H3533_027_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	31		31																								31		31				31		31			31			31								Preferred Generic, 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	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
H3533	033	0	1	01	01	H3533_033_0	4			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	4			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	033	0	1	01	01	H3533_033_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		95.00	35.00		35.00
H3533	033	0	1	01	01	H3533_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	26		26																								26		26				26		26			26			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
H3533	033	0	1	01	01	H3533_033_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
H3533	035	0	1	01	01	H3533_035_0	4			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	035	0	1	01	01	H3533_035_0	4			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	035	0	1	01	01	H3533_035_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		95.00	35.00		35.00
H3533	035	0	1	01	01	H3533_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	26		26																								26		26				26		26			26			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
H3533	035	0	1	01	01	H3533_035_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
H3536	002	0	1	02	01	H3536_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	02	01	H3536_002_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H3536	002	0	1	02	01	H3536_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											66.06	20	20	20				66.06	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	70.00				35.00		35.00
H3536	002	0	1	02	01	H3536_002_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											60.26	35	35	35				60.26	35	35	35				35	35	35															35			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
H3536	002	0	1	02	01	H3536_002_0	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, Select Care Drugs																								
H3536	002	0	1	02	01	H3536_002_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																								
H3536	004	0	1	01	01	H3536_004_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3536	004	0	1	01	01	H3536_004_0	5			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.56	25	25	25																		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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				56.48	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
H3536	004	0	1	01	01	H3536_004_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				35.15	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
H3536	004	0	1	01	01	H3536_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	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	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																								
H3536	006	0	1	02	01	H3536_006_0	8			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																								
H3536	006	0	1	02	01	H3536_006_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																								
H3536	006	0	1	02	01	H3536_006_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.55	25	25	25				58.04	20	20	20				20	20	20															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	70.00				35.00		35.00
H3536	006	0	1	02	01	H3536_006_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											35.23	25	25	25				35.23	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		35.00
H3536	006	0	1	02	01	H3536_006_0	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, Select Care Drugs																								
H3536	006	0	1	02	01	H3536_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																								
H3551	001	0	1	01	01	H3551_001_0	8			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3551	001	0	1	01	01	H3551_001_0	8			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H3551	001	0	1	01	01	H3551_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	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
H3551	001	0	1	01	01	H3551_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				98.90	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	70.00				35.00		35.00
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				716.26	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H3551	002	0	1	01	01	H3551_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3551	002	0	1	01	01	H3551_002_0	6			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H3551	002	0	1	01	01	H3551_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	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
H3551	002	0	1	01	01	H3551_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				86.67	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	70.00				35.00		35.00
H3551	002	0	1	01	01	H3551_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				636.07	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H3554	002	0	1	04	01	H3554_002_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																								
H3554	002	0	1	04	01	H3554_002_0	4			Generic	4	11	3	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	10.00		25.00																			10.00		0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3554	002	0	1	04	01	H3554_002_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		131.00																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
H3554	002	0	1	04	01	H3554_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				98.86	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		35.00
H3554	002	0	1	04	01	H3554_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				74.44	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
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		2.50																			1.00		0.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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		25.00																			10.00		0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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		131.00																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
H3554	007	0	1	04	01	H3554_007_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				85.72	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
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				55.10	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H3597	001	0	1	02	01	H3597_001_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3597	001	0	1	02	01	H3597_001_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3597	001	0	1	02	01	H3597_001_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.19	25	25	25				118.28	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
H3597	001	0	1	02	01	H3597_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.72	26	26	26				40.13	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	02	01	H3597_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1178.82	30						1122.28	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
H3597	007	0	1	02	01	H3597_007_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3597	007	0	1	02	01	H3597_007_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3597	007	0	1	02	01	H3597_007_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											97.47	25	25	25				115.39	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
H3597	007	0	1	02	01	H3597_007_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.13	26	26	26				38.80	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	02	01	H3597_007_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.30	30						769.13	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
H3597	009	0	1	02	01	H3597_009_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3597	009	0	1	02	01	H3597_009_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3597	009	0	1	02	01	H3597_009_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.20	25	25	25				102.56	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
H3597	009	0	1	02	01	H3597_009_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.21	26	26	26				35.55	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	02	01	H3597_009_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											978.39	30						1099.01	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	02	01	H3597_014_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3597	014	0	1	02	01	H3597_014_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3597	014	0	1	02	01	H3597_014_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.00	25	25	25				105.96	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
H3597	014	0	1	02	01	H3597_014_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.34	26	26	26				34.65	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	02	01	H3597_014_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											993.24	30						950.16	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
H3653	004	0	1	02	01	H3653_004_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
H3653	004	0	1	02	01	H3653_004_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
H3653	004	0	1	02	01	H3653_004_0	10			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	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
H3653	004	0	1	02	01	H3653_004_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				292.82	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	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
H3653	015	0	1	02	01	H3653_015_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
H3653	015	0	1	02	01	H3653_015_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
H3653	015	0	1	02	01	H3653_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		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	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				280.63	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			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			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				345.33	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	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	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	7			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	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																			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	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		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	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				300.12	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00												35.00		35.00
H3655	034	0	1	02	01	H3655_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								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	02	01	H3655_034_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																								
H3655	034	0	1	02	01	H3655_034_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.17	25	25	25				44.13	20	20	20				20	20	20															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	70.00				35.00		35.00
H3655	034	0	1	02	01	H3655_034_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											44.10	35	35	35				44.10	35	35	35				35	35	35															35			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
H3655	034	0	1	02	01	H3655_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																								
H3655	034	0	1	02	01	H3655_034_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																								
H3655	041	0	1	02	01	H3655_041_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																								
H3655	041	0	1	02	01	H3655_041_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				11.88	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3655	041	0	1	02	01	H3655_041_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				71.27	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
H3655	041	0	1	02	01	H3655_041_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				37.74	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
H3655	041	0	1	02	01	H3655_041_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3655	041	0	1	02	01	H3655_041_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																								
H3655	045	1	1	02	01	H3655_045_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																								
H3655	045	1	1	02	01	H3655_045_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																								
H3655	045	1	1	02	01	H3655_045_1	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.52	25	25	25				45.22	20	20	20				20	20	20															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	70.00				35.00		35.00
H3655	045	1	1	02	01	H3655_045_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											60.60	50	50	50				60.60	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		35.00
H3655	045	1	1	02	01	H3655_045_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																								
H3655	045	1	1	02	01	H3655_045_1	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																								
H3655	045	2	1	02	01	H3655_045_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																								
H3655	045	2	1	02	01	H3655_045_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																								
H3655	045	2	1	02	01	H3655_045_2	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.52	25	25	25				45.22	20	20	20				20	20	20															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	70.00				35.00		35.00
H3655	045	2	1	02	01	H3655_045_2	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											60.60	50	50	50				60.60	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		35.00
H3655	045	2	1	02	01	H3655_045_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																								
H3655	045	2	1	02	01	H3655_045_2	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																								
H3655	045	3	1	02	01	H3655_045_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																								
H3655	045	3	1	02	01	H3655_045_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																								
H3655	045	3	1	02	01	H3655_045_3	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.52	25	25	25				45.22	20	20	20				20	20	20															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	70.00				35.00		35.00
H3655	045	3	1	02	01	H3655_045_3	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											60.60	50	50	50				60.60	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		35.00
H3655	045	3	1	02	01	H3655_045_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																								
H3655	045	3	1	02	01	H3655_045_3	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																								
H3655	045	4	1	02	01	H3655_045_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																								
H3655	045	4	1	02	01	H3655_045_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																								
H3655	045	4	1	02	01	H3655_045_4	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.52	25	25	25				45.22	20	20	20				20	20	20															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	70.00				35.00		35.00
H3655	045	4	1	02	01	H3655_045_4	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											60.60	50	50	50				60.60	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		35.00
H3655	045	4	1	02	01	H3655_045_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																								
H3655	045	4	1	02	01	H3655_045_4	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																								
H3655	047	0	1	02	01	H3655_047_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																								
H3655	047	0	1	02	01	H3655_047_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																								
H3655	047	0	1	02	01	H3655_047_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.92	25	25	25				52.74	20	20	20				20	20	20															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	70.00				35.00		35.00
H3655	047	0	1	02	01	H3655_047_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											61.48	50	50	50				61.48	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		35.00
H3655	047	0	1	02	01	H3655_047_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																								
H3655	047	0	1	02	01	H3655_047_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																								
H3660	028	0	1	02	01	H3660_028_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	028	0	1	02	01	H3660_028_0	9			Generic	4	11	1	2	2	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, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H3660	028	0	1	02	01	H3660_028_0	9			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	9			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	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				666.55	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	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	029	0	1	02	01	H3660_029_0	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	029	0	1	02	01	H3660_029_0	10			Generic	4	11	1	2	2	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, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H3660	029	0	1	02	01	H3660_029_0	10			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	029	0	1	02	01	H3660_029_0	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	029	0	1	02	01	H3660_029_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				809.32	32																				32																	32			32								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	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	044	0	1	01	01	H3660_044_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	044	0	1	01	01	H3660_044_0	9			Generic	4	11	1	2	2	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, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H3660	044	0	1	01	01	H3660_044_0	9			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	47.00		117.50																					117.50																47.00				47.00		1.57						1.52	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	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	044	0	1	01	01	H3660_044_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				595.62	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
H3660	044	0	1	01	01	H3660_044_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	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	050	0	1	01	01	H3660_050_0	10			Generic	4	11	1	2	2	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, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H3660	050	0	1	01	01	H3660_050_0	10			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	47.00		117.50																					117.50																47.00				47.00		1.57						1.51	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	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	050	0	1	01	01	H3660_050_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				817.86	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
H3660	050	0	1	01	01	H3660_050_0	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	053	1	1	01	01	H3660_053_1	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	053	1	1	01	01	H3660_053_1	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	053	1	1	01	01	H3660_053_1	10			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	47.00		117.50																					117.50																47.00				47.00		1.57						1.52	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	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	053	1	1	01	01	H3660_053_1	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1074.84	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
H3660	053	1	1	01	01	H3660_053_1	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	053	2	1	01	01	H3660_053_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	053	2	1	01	01	H3660_053_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	053	2	1	01	01	H3660_053_2	10			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	47.00		117.50																					117.50																47.00				47.00		1.57						1.52	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	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	053	2	1	01	01	H3660_053_2	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1074.84	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
H3660	053	2	1	01	01	H3660_053_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	1	1	01	01	H3660_056_1	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	1	1	01	01	H3660_056_1	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	1	1	01	01	H3660_056_1	10			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	47.00		117.50																					117.50																47.00				47.00		1.57						1.52	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	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	1	1	01	01	H3660_056_1	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				858.02	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
H3660	056	1	1	01	01	H3660_056_1	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			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			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	47.00		117.50																					117.50																47.00				47.00		1.57						1.52	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				858.02	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
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
H3664	017	0	1	02	01	H3664_017_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					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	4			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	4			Preferred Brand	4	11	1	3	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00	78.82	20	20	20	47.00	94.00	141.00	78.82	20	20	20	47.00	94.00	141.00	20	20	20													47.00		20		47.00	20		1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											70.93	50	50	50				70.93	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
H3664	017	0	1	02	01	H3664_017_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											652.68	33						652.68	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3664	020	0	1	02	01	H3664_020_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					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	4			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	4			Preferred Brand	4	11	1	3	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00	77.31	20	20	20	47.00	94.00	141.00	77.31	20	20	20	47.00	94.00	141.00	20	20	20													47.00		20		47.00	20		1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											71.08	50	50	50				71.08	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
H3664	020	0	1	02	01	H3664_020_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1035.73	33						1035.73	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3664	021	0	1	02	01	H3664_021_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					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	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					12.00	24.00	36.00					12.00	24.00	30.00																20.00				12.00			0.67	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3664	021	0	1	02	01	H3664_021_0	4			Preferred Brand	4	11	1	3	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00	79.11	20	20	20	47.00	94.00	141.00	79.11	20	20	20	47.00	94.00	141.00	20	20	20													47.00		20		47.00	20		1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											73.19	50	50	50				73.19	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	70.00	105.00				35.00		35.00
H3664	021	0	1	02	01	H3664_021_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1022.43	33						1022.43	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3668	018	1	1	01	01	H3668_018_1	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										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	7			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	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										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	7			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	7			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	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										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	7			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	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										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	7			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	7			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				47.91	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	70.00				35.00		35.00
H3668	019	1	1	01	01	H3668_019_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				89.43	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
H3668	019	1	1	01	01	H3668_019_1	7			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				47.91	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	70.00				35.00		35.00
H3668	019	2	1	01	01	H3668_019_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				89.43	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
H3668	019	2	1	01	01	H3668_019_2	7			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	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										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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				48.88	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	70.00				35.00		35.00
H3668	020	0	1	01	01	H3668_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				90.09	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
H3668	020	0	1	01	01	H3668_020_0	6			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	6			Preferred Generic	4	11	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										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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				49.31	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	70.00				35.00		35.00
H3668	022	0	1	01	01	H3668_022_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				98.17	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
H3668	022	0	1	01	01	H3668_022_0	6			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	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										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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				46.47	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	70.00				35.00		35.00
H3668	023	0	1	01	01	H3668_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				90.63	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
H3668	023	0	1	01	01	H3668_023_0	6			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				45.81	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	70.00				35.00		35.00
H3668	025	0	1	01	01	H3668_025_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				83.53	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	70.00				35.00		35.00
H3668	025	0	1	01	01	H3668_025_0	7			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				38.66	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	70.00				35.00		35.00
H3668	026	0	1	01	01	H3668_026_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				76.90	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
H3668	026	0	1	01	01	H3668_026_0	7			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	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										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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				67.39	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	70.00				35.00		35.00
H3668	030	0	1	01	01	H3668_030_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				92.70	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	70.00				35.00		35.00
H3668	030	0	1	01	01	H3668_030_0	6			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
H3668	031	0	1	01	01	H3668_031_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				57.79	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	70.00				35.00		35.00
H3668	031	0	1	01	01	H3668_031_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				88.47	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
H3668	031	0	1	01	01	H3668_031_0	7			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
H3672	013	0	1	01	01	H3672_013_0	10			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	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					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	013	0	1	01	01	H3672_013_0	10			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.89	20	20	20				52.22	20	20	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	70.00	105.00	35.00		35.00
H3672	013	0	1	01	01	H3672_013_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.49	40	40	40				27.47	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
H3672	013	0	1	01	01	H3672_013_0	10			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	7			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	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										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	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.55	20	20	20				55.20	20	20	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	70.00	105.00	35.00		35.00
H3672	020	0	1	01	01	H3672_020_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											34.58	40	40	40				28.82	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
H3672	020	0	1	01	01	H3672_020_0	7			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	7			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	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										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	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.99	20	20	20				53.31	20	20	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	70.00	105.00	35.00		35.00
H3672	023	0	1	01	01	H3672_023_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											39.24	40	40	40				31.90	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
H3672	023	0	1	01	01	H3672_023_0	7			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	6			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	2				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	6			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				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	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	001	0	1	01	01	H3706_001_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	35.00		35.00
H3706	001	0	1	01	01	H3706_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											208.34	33						171.55	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
H3706	023	0	1	01	01	H3706_023_0	6			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	2				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	6			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				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	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	023	0	1	01	01	H3706_023_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	35.00		35.00
H3706	023	0	1	01	01	H3706_023_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											213.09	33						194.59	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
H3706	024	0	1	01	01	H3706_024_0	10			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	2				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	10			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				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	10			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	10			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	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											197.14	33						183.65	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
H3706	025	0	1	01	01	H3706_025_0	9			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	2				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	9			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				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	9			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	9			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	025	0	1	01	01	H3706_025_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											193.27	33						185.32	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
H3727	001	1	1	01	01	H3727_001_1	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																			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	3			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										17.00	34.00	51.00				15.00	30.00	45.00				17.00		17.00
H3727	001	1	1	01	01	H3727_001_1	3			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	3			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										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	3			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	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																			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	3			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										17.00	34.00	51.00				15.00	30.00	45.00				17.00		17.00
H3727	001	2	1	01	01	H3727_001_2	3			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	3			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										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	3			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	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																			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	3			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										17.00	34.00	51.00				15.00	30.00	45.00				17.00		17.00
H3727	001	3	1	01	01	H3727_001_3	3			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	3			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										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	3			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	3			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	3			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										8.00	16.00	24.00				8.00	16.00	24.00				8.00		8.00
H3727	004	1	1	01	01	H3727_004_1	3			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	3			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										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	3			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	3			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	3			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										8.00	16.00	24.00				8.00	16.00	24.00				8.00		8.00
H3727	004	2	1	01	01	H3727_004_2	3			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	3			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										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	3			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	3			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	3			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										8.00	16.00	24.00				8.00	16.00	24.00				8.00		8.00
H3727	004	3	1	01	01	H3727_004_3	3			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	3			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										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	3			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	3			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	3			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										10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H3727	005	1	1	01	01	H3727_005_1	3			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	3			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										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	3			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	3			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	3			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										10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H3727	005	2	1	01	01	H3727_005_2	3			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	3			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										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	3			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	3			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	3			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										10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H3727	005	3	1	01	01	H3727_005_3	3			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	3			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										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	3			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	003	0	1	02	01	H3748_003_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3748	003	0	1	02	01	H3748_003_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3748	003	0	1	02	01	H3748_003_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.51	24	24	24				114.65	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
H3748	003	0	1	02	01	H3748_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.75	25	25	25				30.91	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
H3748	003	0	1	02	01	H3748_003_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.08	25						826.73	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
H3748	006	0	1	02	01	H3748_006_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3748	006	0	1	02	01	H3748_006_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3748	006	0	1	02	01	H3748_006_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.49	24	24	24				103.06	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
H3748	006	0	1	02	01	H3748_006_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.02	25	25	25				34.34	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
H3748	006	0	1	02	01	H3748_006_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											985.51	25						854.64	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
H3748	017	0	1	02	01	H3748_017_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3748	017	0	1	02	01	H3748_017_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3748	017	0	1	02	01	H3748_017_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.22	22	22	22				40.80	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	017	0	1	02	01	H3748_017_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.21	25	25	25				44.33	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
H3748	017	0	1	02	01	H3748_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											346.91	25						302.25	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
H3755	001	0	1	01	01	H3755_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
H3755	001	0	1	01	01	H3755_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
H3755	001	0	1	01	01	H3755_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	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
H3755	001	0	1	01	01	H3755_001_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				70.00	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
H3755	001	0	1	01	01	H3755_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				820.00	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
H3755	004	0	1	01	01	H3755_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	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	004	0	1	01	01	H3755_004_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	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
H3755	004	0	1	01	01	H3755_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				65.00	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
H3755	004	0	1	01	01	H3755_004_0	4			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				862.00	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
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			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	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	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
H3755	005	0	1	01	01	H3755_005_0	4			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	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
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				876.00	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
H3755	006	0	1	01	01	H3755_006_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	006	0	1	01	01	H3755_006_0	6		N	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3755	006	0	1	01	01	H3755_006_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.56	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	70.00				35.00		35.00
H3755	006	0	1	01	01	H3755_006_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.56	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	70.00				35.00		35.00
H3755	006	0	1	01	01	H3755_006_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				775.46	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	70.00				35.00		35.00
H3777	001	2	1	01	01	H3777_001_2	15			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	15			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	15			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	15			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	15			Specialty Tier	4	11	1	1	5	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	15			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	15			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	15			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	15			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	15			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	15			Specialty Tier	4	11	1	1	5	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	15			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	15			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	15			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	15			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	15			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	15			Specialty Tier	4	11	1	1	5	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	15			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																								
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				213.00	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
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			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																								
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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	015	0	1	02	01	H3805_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				160.00	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
H3805	017	0	1	02	01	H3805_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																								
H3805	017	0	1	02	01	H3805_017_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																								
H3805	017	0	1	02	01	H3805_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
H3805	017	0	1	02	01	H3805_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3805	017	0	1	02	01	H3805_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				177.00	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
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			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																								
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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	033	0	1	02	01	H3805_033_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				163.00	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
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			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																								
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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	034	0	1	02	01	H3805_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				177.00	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
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			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																								
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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	037	0	1	02	01	H3805_037_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				209.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				185.00	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
H3805	039	2	1	02	01	H3805_039_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																								
H3805	039	2	1	02	01	H3805_039_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																								
H3805	039	2	1	02	01	H3805_039_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
H3805	039	2	1	02	01	H3805_039_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3805	039	2	1	02	01	H3805_039_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H3805	040	0	1	02	01	H3805_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																								
H3805	040	0	1	02	01	H3805_040_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	040	0	1	02	01	H3805_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
H3805	040	0	1	02	01	H3805_040_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3805	040	0	1	02	01	H3805_040_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H3805	041	0	1	02	01	H3805_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																								
H3805	041	0	1	02	01	H3805_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																								
H3805	041	0	1	02	01	H3805_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
H3805	041	0	1	02	01	H3805_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3805	041	0	1	02	01	H3805_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				180.00	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
H3805	043	0	1	02	01	H3805_043_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	043	0	1	02	01	H3805_043_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	043	0	1	02	01	H3805_043_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
H3805	043	0	1	02	01	H3805_043_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3805	043	0	1	02	01	H3805_043_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
H3805	044	0	1	02	01	H3805_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																								
H3805	044	0	1	02	01	H3805_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																								
H3805	044	0	1	02	01	H3805_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
H3805	044	0	1	02	01	H3805_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3805	044	0	1	02	01	H3805_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				159.00	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
H3805	045	0	1	02	01	H3805_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																								
H3805	045	0	1	02	01	H3805_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																								
H3805	045	0	1	02	01	H3805_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
H3805	045	0	1	02	01	H3805_045_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H3805	045	0	1	02	01	H3805_045_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				158.00	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
H3811	002	0	1	01	01	H3811_002_0	7			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								13.00		26.00					3.00		6.00													26.00						6.00				13.00				13.00			0.43	0.10				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										13.00		26.00	3.00		6.00			26.00			6.00	13.00		13.00
H3811	002	0	1	01	01	H3811_002_0	7			Generic	4	11	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		40.00					12.00		24.00													40.00						24.00				20.00				20.00			0.67	0.40				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										20.00		40.00	12.00		24.00			40.00			24.00	20.00		20.00
H3811	002	0	1	01	01	H3811_002_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		94.00					40.00		80.00													94.00						80.00				47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		94.00	35.00		80.00			94.00			80.00	35.00		35.00
H3811	002	0	1	01	01	H3811_002_0	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	1	2						90	30		31											76.00	50		50				59.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3811	002	0	1	01	01	H3811_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1617.00	29						595.00	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	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				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	7			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								13.00		26.00					3.00		6.00													26.00						6.00				13.00				13.00			0.43	0.10				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										13.00		26.00	3.00		6.00			26.00			6.00	13.00		13.00
H3811	009	0	1	01	01	H3811_009_0	7			Generic	4	11	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		40.00					12.00		24.00													40.00						24.00				20.00				20.00			0.67	0.40				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										20.00		40.00	12.00		24.00			40.00			24.00	20.00		20.00
H3811	009	0	1	01	01	H3811_009_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		94.00					40.00		80.00													94.00						80.00				47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		94.00	35.00		80.00			94.00			80.00	35.00		35.00
H3811	009	0	1	01	01	H3811_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	1	2						90	30		31											48.00	50		50				54.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3811	009	0	1	01	01	H3811_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1489.00	33						970.00	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	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				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3814	031	0	1	01	01	H3814_031_0	11			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	11			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										20.00		40.00						40.00				20.00		20.00
H3814	031	0	1	01	01	H3814_031_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
H3814	031	0	1	01	01	H3814_031_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										35.00		70.00						70.00				35.00		35.00
H3814	031	0	1	01	01	H3814_031_0	11			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	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																								
H3815	001	0	1	01	01	H3815_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
H3815	001	0	1	01	01	H3815_001_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	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	11			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	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	001	0	1	01	01	H3815_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				564.25	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	11			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	007	0	1	01	01	H3815_007_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	007	0	1	01	01	H3815_007_0	16			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	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	007	0	1	01	01	H3815_007_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	007	0	1	01	01	H3815_007_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				578.23	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	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	008	0	1	01	01	H3815_008_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
H3815	008	0	1	01	01	H3815_008_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
H3815	008	0	1	01	01	H3815_008_0	12			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	12			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	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				553.69	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	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																								
H3815	010	0	1	01	01	H3815_010_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
H3815	010	0	1	01	01	H3815_010_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
H3815	010	0	1	01	01	H3815_010_0	12			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	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
H3815	010	0	1	01	01	H3815_010_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				400.19	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	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																								
H3815	011	0	1	01	01	H3815_011_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
H3815	011	0	1	01	01	H3815_011_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	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	10			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	10			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	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				532.58	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	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																								
H3815	013	0	1	01	01	H3815_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										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	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
H3815	013	0	1	01	01	H3815_013_0	10			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	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
H3815	013	0	1	01	01	H3815_013_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				521.82	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	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																								
H3815	016	0	1	02	01	H3815_016_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
H3815	016	0	1	02	01	H3815_016_0	10			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	10			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	10			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	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				545.38	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	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																								
H3815	019	0	1	01	01	H3815_019_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	019	0	1	01	01	H3815_019_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
H3815	019	0	1	01	01	H3815_019_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	019	0	1	01	01	H3815_019_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	019	0	1	01	01	H3815_019_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				535.30	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	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	020	0	1	01	01	H3815_020_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	020	0	1	01	01	H3815_020_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
H3815	020	0	1	01	01	H3815_020_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	020	0	1	01	01	H3815_020_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	020	0	1	01	01	H3815_020_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				561.71	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	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	021	0	1	01	01	H3815_021_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	021	0	1	01	01	H3815_021_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
H3815	021	0	1	01	01	H3815_021_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	021	0	1	01	01	H3815_021_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	021	0	1	01	01	H3815_021_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				470.41	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	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	023	0	1	01	01	H3815_023_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	023	0	1	01	01	H3815_023_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
H3815	023	0	1	01	01	H3815_023_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	023	0	1	01	01	H3815_023_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	023	0	1	01	01	H3815_023_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				407.79	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	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	028	0	1	01	01	H3815_028_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	028	0	1	01	01	H3815_028_0	11			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	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	028	0	1	01	01	H3815_028_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	028	0	1	01	01	H3815_028_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				591.43	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	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	031	0	1	01	01	H3815_031_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	031	0	1	01	01	H3815_031_0	11			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	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	031	0	1	01	01	H3815_031_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	031	0	1	01	01	H3815_031_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				619.07	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	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	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
H3815	033	0	1	01	01	H3815_033_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	Preferred 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	9			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	9			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	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				443.14	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	9			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	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	034	0	1	01	01	H3815_034_0	11			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	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	034	0	1	01	01	H3815_034_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	034	0	1	01	01	H3815_034_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				511.48	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	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	035	0	1	01	01	H3815_035_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	035	0	1	01	01	H3815_035_0	11			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	035	0	1	01	01	H3815_035_0	11			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	035	0	1	01	01	H3815_035_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	035	0	1	01	01	H3815_035_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				528.60	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	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	037	0	1	01	01	H3815_037_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
H3815	037	0	1	01	01	H3815_037_0	10			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	10			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	10			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	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				651.25	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	10			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	038	0	1	01	01	H3815_038_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
H3815	038	0	1	01	01	H3815_038_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
H3815	038	0	1	01	01	H3815_038_0	10			Preferred Brand	4	11	3	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, 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	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
H3815	038	0	1	01	01	H3815_038_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				433.27	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	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																								
H3815	040	0	1	01	01	H3815_040_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
H3815	040	0	1	01	01	H3815_040_0	10			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	040	0	1	01	01	H3815_040_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
H3815	040	0	1	01	01	H3815_040_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
H3815	040	0	1	01	01	H3815_040_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				433.81	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	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																								
H3815	043	0	1	01	01	H3815_043_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	043	0	1	01	01	H3815_043_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	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
H3815	043	0	1	01	01	H3815_043_0	11			Preferred Brand	4	11	3	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				87.99	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	043	0	1	01	01	H3815_043_0	11			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				43.17	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	043	0	1	01	01	H3815_043_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				433.14	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3815	043	0	1	01	01	H3815_043_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	046	0	1	01	01	H3815_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, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	046	0	1	01	01	H3815_046_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	046	0	1	01	01	H3815_046_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	046	0	1	01	01	H3815_046_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	046	0	1	01	01	H3815_046_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				528.19	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3815	046	0	1	01	01	H3815_046_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	047	0	1	01	01	H3815_047_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	047	0	1	01	01	H3815_047_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	047	0	1	01	01	H3815_047_0	11			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	047	0	1	01	01	H3815_047_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	047	0	1	01	01	H3815_047_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				526.26	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3815	047	0	1	01	01	H3815_047_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	048	0	1	01	01	H3815_048_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
H3815	048	0	1	01	01	H3815_048_0	10			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	048	0	1	01	01	H3815_048_0	10			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	048	0	1	01	01	H3815_048_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	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	048	0	1	01	01	H3815_048_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				524.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3815	048	0	1	01	01	H3815_048_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																								
H3815	049	0	1	01	01	H3815_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, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	049	0	1	01	01	H3815_049_0	10			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	049	0	1	01	01	H3815_049_0	10			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	049	0	1	01	01	H3815_049_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
H3815	049	0	1	01	01	H3815_049_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				564.58	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3815	049	0	1	01	01	H3815_049_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	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																								
H3817	008	1	1	04	01	H3817_008_1	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H3817	008	1	1	04	01	H3817_008_1	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					10.00	20.00	20.00											13.00	26.00	26.00				10.00	20.00	20.00				13.00				13.00			0.43	0.33		0.43	0.33	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	10.00	20.00	20.00	13.00	26.00	26.00	10.00	20.00	20.00	13.00		13.00
H3817	008	1	1	04	01	H3817_008_1	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											58.74	25	25	25				58.74	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H3817	008	1	1	04	01	H3817_008_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											63.08	43	43	43				63.08	40	40	40										43	43	43				40	40	40			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
H3817	008	1	1	04	01	H3817_008_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1001.14	32						1001.14	32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3817	008	2	1	04	01	H3817_008_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H3817	008	2	1	04	01	H3817_008_2	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					10.00	20.00	20.00											13.00	26.00	26.00				10.00	20.00	20.00				13.00				13.00			0.43	0.33		0.43	0.33	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	10.00	20.00	20.00	13.00	26.00	26.00	10.00	20.00	20.00	13.00		13.00
H3817	008	2	1	04	01	H3817_008_2	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											58.74	25	25	25				58.74	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H3817	008	2	1	04	01	H3817_008_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											63.08	43	43	43				63.08	40	40	40										43	43	43				40	40	40			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
H3817	008	2	1	04	01	H3817_008_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1001.14	32						1001.14	32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3817	008	4	1	04	01	H3817_008_4	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H3817	008	4	1	04	01	H3817_008_4	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					10.00	20.00	20.00											13.00	26.00	26.00				10.00	20.00	20.00				13.00				13.00			0.43	0.33		0.43	0.33	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	10.00	20.00	20.00	13.00	26.00	26.00	10.00	20.00	20.00	13.00		13.00
H3817	008	4	1	04	01	H3817_008_4	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											58.74	25	25	25				58.74	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H3817	008	4	1	04	01	H3817_008_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											63.08	43	43	43				63.08	40	40	40										43	43	43				40	40	40			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
H3817	008	4	1	04	01	H3817_008_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1001.14	32						1001.14	32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3817	009	1	1	04	01	H3817_009_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H3817	009	1	1	04	01	H3817_009_1	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					10.00	20.00	20.00											13.00	26.00	26.00				10.00	20.00	20.00				13.00				13.00			0.43	0.33		0.43	0.33	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	10.00	20.00	20.00	13.00	26.00	26.00	10.00	20.00	20.00	13.00		13.00
H3817	009	1	1	04	01	H3817_009_1	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											60.62	25	25	25				60.62	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H3817	009	1	1	04	01	H3817_009_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.31	43	43	43				80.31	40	40	40										43	43	43				40	40	40			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
H3817	009	1	1	04	01	H3817_009_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1061.54	33						1061.54	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3817	009	2	1	04	01	H3817_009_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H3817	009	2	1	04	01	H3817_009_2	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					10.00	20.00	20.00											13.00	26.00	26.00				10.00	20.00	20.00				13.00				13.00			0.43	0.33		0.43	0.33	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	10.00	20.00	20.00	13.00	26.00	26.00	10.00	20.00	20.00	13.00		13.00
H3817	009	2	1	04	01	H3817_009_2	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											60.62	25	25	25				60.62	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H3817	009	2	1	04	01	H3817_009_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.31	43	43	43				80.31	40	40	40										43	43	43				40	40	40			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
H3817	009	2	1	04	01	H3817_009_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1061.54	33						1061.54	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3817	011	1	1	04	01	H3817_011_1	5			Preferred Generic	4	01	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										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
H3817	011	1	1	04	01	H3817_011_1	5			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					2.00	4.00	6.00											6.00	12.00	18.00				2.00	4.00	0.00				6.00				6.00			0.20	0.07		0.20	0.07	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										6.00	12.00	18.00	2.00	4.00	6.00	6.00	12.00	18.00	2.00	4.00	0.00	6.00		6.00
H3817	011	1	1	04	01	H3817_011_1	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.75	23	23	23				41.75	19	19	19										23	23	23				19	19	19			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
H3817	011	1	1	04	01	H3817_011_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											64.75	43	43	43				64.75	40	40	40										43	43	43				40	40	40			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
H3817	011	1	1	04	01	H3817_011_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											857.81	31						857.81	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3817	011	2	1	04	01	H3817_011_2	5			Preferred Generic	4	01	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										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
H3817	011	2	1	04	01	H3817_011_2	5			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					2.00	4.00	6.00											6.00	12.00	18.00				2.00	4.00	0.00				6.00				6.00			0.20	0.07		0.20	0.07	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										6.00	12.00	18.00	2.00	4.00	6.00	6.00	12.00	18.00	2.00	4.00	0.00	6.00		6.00
H3817	011	2	1	04	01	H3817_011_2	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.75	23	23	23				41.75	19	19	19										23	23	23				19	19	19			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
H3817	011	2	1	04	01	H3817_011_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											64.75	43	43	43				64.75	40	40	40										43	43	43				40	40	40			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
H3817	011	2	1	04	01	H3817_011_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											857.81	31						857.81	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3817	011	3	1	04	01	H3817_011_3	5			Preferred Generic	4	01	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										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
H3817	011	3	1	04	01	H3817_011_3	5			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					2.00	4.00	6.00											6.00	12.00	18.00				2.00	4.00	0.00				6.00				6.00			0.20	0.07		0.20	0.07	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										6.00	12.00	18.00	2.00	4.00	6.00	6.00	12.00	18.00	2.00	4.00	0.00	6.00		6.00
H3817	011	3	1	04	01	H3817_011_3	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.75	23	23	23				41.75	19	19	19										23	23	23				19	19	19			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
H3817	011	3	1	04	01	H3817_011_3	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											64.75	43	43	43				64.75	40	40	40										43	43	43				40	40	40			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
H3817	011	3	1	04	01	H3817_011_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											857.81	31						857.81	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3822	001	0	1	01	01	H3822_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3822	001	0	1	01	01	H3822_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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3822	001	0	1	01	01	H3822_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	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	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.25	50	50	50				99.50	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
H3822	001	0	1	01	01	H3822_001_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											617.11	33						606.28	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3822	002	0	1	01	01	H3822_002_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3822	002	0	1	01	01	H3822_002_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3822	002	0	1	01	01	H3822_002_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	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.04	50	50	50				82.85	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
H3822	002	0	1	01	01	H3822_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											572.33	30						477.54	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3822	007	0	1	02	01	H3822_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3822	007	0	1	02	01	H3822_007_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3822	007	0	1	02	01	H3822_007_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	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.32	50	50	50				86.4	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
H3822	007	0	1	02	01	H3822_007_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.00	33						592.89	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3822	008	0	1	02	01	H3822_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3822	008	0	1	02	01	H3822_008_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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3822	008	0	1	02	01	H3822_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	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	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.23	50	50	50				85.21	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	105.00	35.00		35.00
H3822	008	0	1	02	01	H3822_008_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											602.97	33						553.11	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3822	012	0	1	01	01	H3822_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3822	012	0	1	01	01	H3822_012_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3822	012	0	1	01	01	H3822_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	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											74.32	50	50	50				77.97	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
H3822	012	0	1	01	01	H3822_012_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											713.93	33						572.59	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3822	014	0	1	01	01	H3822_014_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3822	014	0	1	01	01	H3822_014_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3822	014	0	1	01	01	H3822_014_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	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											64.63	50	50	50				75.39	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
H3822	014	0	1	01	01	H3822_014_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											733.41	33						582.09	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3828	001	0	1	04	01	H3828_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								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	7			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	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											61.22	25	25	25				56.19	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
H3828	001	0	1	04	01	H3828_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											88.31	50	50	50				95.89	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	70.00				35.00		35.00
H3828	001	0	1	04	01	H3828_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											950.00	31						950.00	31						31																	31			31								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	5			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	5			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	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																			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	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	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	5			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	6			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	6			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	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	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	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	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	6			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	6			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	6			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	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	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	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	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	6			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	5			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	5			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	5			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	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
H3832	010	0	1	04	01	H3832_010_0	5			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					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																								
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																								
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					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
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											18.65	33	33	33				17.51	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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											48.65	33						56.15	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
H3864	014	0	1	02	01	H3864_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								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																								
H3864	014	0	1	02	01	H3864_014_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																								
H3864	014	0	1	02	01	H3864_014_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	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
H3864	014	0	1	02	01	H3864_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											27.69	33	33	33				26.52	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3864	014	0	1	02	01	H3864_014_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											92.53	30						105.14	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
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																								
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																								
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					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
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											29.87	31	31	31				28.37	30	30	30										31	31	31				30	30	30			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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											119.83	30						138.74	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
H3864	027	0	1	01	01	H3864_027_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																								
H3864	027	0	1	01	01	H3864_027_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																								
H3864	027	0	1	01	01	H3864_027_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	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
H3864	027	0	1	01	01	H3864_027_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											34.45	32	32	32				31.32	31	31	31										32	32	32				31	31	31			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3864	027	0	1	01	01	H3864_027_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											150.19	28						164.30	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
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					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																								
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																								
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					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
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											28.93	33	33	33				26.28	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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											123.80	29						141.04	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
H3864	034	0	1	02	01	H3864_034_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					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																								
H3864	034	0	1	02	01	H3864_034_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					6.00	12.00	18.00											17.00	34.00	51.00				6.00	12.00	12.00				17.00				17.00			0.57	0.20		0.57	0.20	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3864	034	0	1	02	01	H3864_034_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	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
H3864	034	0	1	02	01	H3864_034_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											28.28	33	33	33				24.56	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3864	034	0	1	02	01	H3864_034_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											118.00	30						117.12	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
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					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																								
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																								
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					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
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											35.70	33	33	33				32.31	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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											106.63	26						122.76	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
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																								
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																								
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					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
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											28.38	33	33	33				25.68	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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											129.60	31						111.79	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
H3864	041	0	1	01	01	H3864_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								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																								
H3864	041	0	1	01	01	H3864_041_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																								
H3864	041	0	1	01	01	H3864_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	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
H3864	041	0	1	01	01	H3864_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											29.22	33	33	33				27.09	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3864	041	0	1	01	01	H3864_041_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											104.37	29						102.35	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
H3864	043	0	1	01	01	H3864_043_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																								
H3864	043	0	1	01	01	H3864_043_0	6		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				5.23	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3864	043	0	1	01	01	H3864_043_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				116.91	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
H3864	043	0	1	01	01	H3864_043_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				27.52	27	27	27																		27	27	27															27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3864	043	0	1	01	01	H3864_043_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				160.32	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H3890	001	0	1	04	01	H3890_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
H3890	001	0	1	04	01	H3890_001_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	22.50	30.00																			15.00	22.50	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	22.50	30.00				15.00	22.50	30.00				15.00		15.00
H3890	001	0	1	04	01	H3890_001_0	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				153.12	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	52.50	70.00				35.00		35.00
H3890	001	0	1	04	01	H3890_001_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				150.12	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	52.50	70.00				35.00		35.00
H3890	001	0	1	04	01	H3890_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				747.33	25																				25																	25			25								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	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
H3890	002	0	1	04	01	H3890_002_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	22.50	30.00																			15.00	22.50	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	22.50	30.00				15.00	22.50	30.00				15.00		15.00
H3890	002	0	1	04	01	H3890_002_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				150.50	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	52.50	70.00				35.00		35.00
H3890	002	0	1	04	01	H3890_002_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				164.61	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	52.50	70.00				35.00		35.00
H3890	002	0	1	04	01	H3890_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				841.65	25																				25																	25			25								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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	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	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				155.45	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	52.50	70.00				35.00		35.00
H3890	005	0	1	04	01	H3890_005_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				143.73	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	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				840.03	25																				25																	25			25								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	10			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H3907	006	0	1	01	01	H3907_006_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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H3907	006	0	1	01	01	H3907_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	006	0	1	01	01	H3907_006_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											78.95	50	50	50				100.62	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	006	0	1	01	01	H3907_006_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1576.26	33						1224.52	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	037	0	1	01	01	H3907_037_0	11			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H3907	037	0	1	01	01	H3907_037_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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H3907	037	0	1	01	01	H3907_037_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	037	0	1	01	01	H3907_037_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											97.66	42	42	42				107.79	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	037	0	1	01	01	H3907_037_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1023.88	31						1142.78	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	057	1	1	01	01	H3907_057_1	11			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.00	0.00	0.00	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		0.00
H3907	057	1	1	01	01	H3907_057_1	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				0.00			0.67	0.00		0.00	0.00	0.00	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		0.00
H3907	057	1	1	01	01	H3907_057_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	129.50											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		0.00	0.00	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	1	1	01	01	H3907_057_1	11			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	40	40	40				108.29	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	1	1	01	01	H3907_057_1	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1093.15	31						1094.77	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	057	2	1	01	01	H3907_057_2	11			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.00	0.00	0.00	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		0.00
H3907	057	2	1	01	01	H3907_057_2	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				0.00			0.67	0.00		0.00	0.00	0.00	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		0.00
H3907	057	2	1	01	01	H3907_057_2	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	129.50											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		0.00	0.00	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	2	1	01	01	H3907_057_2	11			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	40	40	40				108.29	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	2	1	01	01	H3907_057_2	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1093.15	31						1094.77	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	057	3	1	01	01	H3907_057_3	11			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.00	0.00	0.00	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		0.00
H3907	057	3	1	01	01	H3907_057_3	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				0.00			0.67	0.00		0.00	0.00	0.00	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		0.00
H3907	057	3	1	01	01	H3907_057_3	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	129.50											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		0.00	0.00	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	3	1	01	01	H3907_057_3	11			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	40	40	40				108.29	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	3	1	01	01	H3907_057_3	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1093.15	31						1094.77	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	057	4	1	01	01	H3907_057_4	11			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.00	0.00	0.00	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		0.00
H3907	057	4	1	01	01	H3907_057_4	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				0.00			0.67	0.00		0.00	0.00	0.00	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		0.00
H3907	057	4	1	01	01	H3907_057_4	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	129.50											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		0.00	0.00	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	4	1	01	01	H3907_057_4	11			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	40	40	40				108.29	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	4	1	01	01	H3907_057_4	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1093.15	31						1094.77	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	057	5	1	01	01	H3907_057_5	11			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.00	0.00	0.00	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		0.00
H3907	057	5	1	01	01	H3907_057_5	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				0.00			0.67	0.00		0.00	0.00	0.00	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		0.00
H3907	057	5	1	01	01	H3907_057_5	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	129.50											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		0.00	0.00	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	5	1	01	01	H3907_057_5	11			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	40	40	40				108.29	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	057	5	1	01	01	H3907_057_5	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1093.15	31						1094.77	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	058	1	1	01	01	H3907_058_1	10			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H3907	058	1	1	01	01	H3907_058_1	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H3907	058	1	1	01	01	H3907_058_1	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	058	1	1	01	01	H3907_058_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											93.17	49	49	49				108.15	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	058	1	1	01	01	H3907_058_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1145.16	33						1286.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	058	2	1	01	01	H3907_058_2	10			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H3907	058	2	1	01	01	H3907_058_2	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H3907	058	2	1	01	01	H3907_058_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	058	2	1	01	01	H3907_058_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											93.17	49	49	49				108.15	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	058	2	1	01	01	H3907_058_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1145.16	33						1286.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	059	1	1	01	01	H3907_059_1	10			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H3907	059	1	1	01	01	H3907_059_1	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H3907	059	1	1	01	01	H3907_059_1	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	059	1	1	01	01	H3907_059_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											77.37	50	50	50				105.57	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	059	1	1	01	01	H3907_059_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											962.10	28						1048.56	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	059	2	1	01	01	H3907_059_2	10			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H3907	059	2	1	01	01	H3907_059_2	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H3907	059	2	1	01	01	H3907_059_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	059	2	1	01	01	H3907_059_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											77.37	50	50	50				105.57	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	059	2	1	01	01	H3907_059_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											962.10	28						1048.56	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3907	059	3	1	01	01	H3907_059_3	11			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H3907	059	3	1	01	01	H3907_059_3	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H3907	059	3	1	01	01	H3907_059_3	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	059	3	1	01	01	H3907_059_3	11			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.37	50	50	50				105.57	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H3907	059	3	1	01	01	H3907_059_3	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											962.10	28						1048.56	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3909	001	0	1	04	01	H3909_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								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	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					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																								
H3909	001	0	1	04	01	H3909_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											67.00	25	25	25				66.00	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	70.00	70.00				35.00		35.00
H3909	001	0	1	04	01	H3909_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											42.00	50	50	50				37.00	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	70.00				35.00		35.00
H3909	001	0	1	04	01	H3909_001_0	5			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	5			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	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					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																								
H3909	009	0	1	04	01	H3909_009_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											68.00	25	25	25				71.00	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	70.00	70.00				35.00		35.00
H3909	009	0	1	04	01	H3909_009_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											43.00	50	50	50				37.00	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	70.00				35.00		35.00
H3909	009	0	1	04	01	H3909_009_0	5			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	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																								
H3909	015	0	1	04	01	H3909_015_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					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																								
H3909	015	0	1	04	01	H3909_015_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											78.00	25	25	25				76.00	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	70.00	70.00				35.00		35.00
H3909	015	0	1	04	01	H3909_015_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											46.00	50	50	50				35.00	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	70.00				35.00		35.00
H3909	015	0	1	04	01	H3909_015_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
H3909	016	0	1	04	01	H3909_016_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	016	0	1	04	01	H3909_016_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	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																								
H3909	016	0	1	04	01	H3909_016_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											74.00	23	23	23				73.00	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	70.00				35.00		35.00
H3909	016	0	1	04	01	H3909_016_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											44.00	50	50	50				34.00	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	70.00				35.00		35.00
H3909	016	0	1	04	01	H3909_016_0	7			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	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										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	5			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	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					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																								
H3909	017	0	1	04	01	H3909_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											83.00	25	25	25				79.00	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	70.00	70.00				35.00		35.00
H3909	017	0	1	04	01	H3909_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											41.00	50	50	50				37.00	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	70.00				35.00		35.00
H3909	017	0	1	04	01	H3909_017_0	5			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	018	0	1	04	01	H3909_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								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	018	0	1	04	01	H3909_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					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																								
H3909	018	0	1	04	01	H3909_018_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											73.00	25	25	25				71.00	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	70.00	70.00				35.00		35.00
H3909	018	0	1	04	01	H3909_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											42.00	50	50	50				36.00	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	70.00				35.00		35.00
H3909	018	0	1	04	01	H3909_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												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	4			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	4			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	4			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	001	0	1	04	01	H3916_001_0	4			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	001	0	1	04	01	H3916_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	002	0	1	04	01	H3916_002_0	5			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	5			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	5			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	5			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	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	005	0	1	04	01	H3916_005_0	6			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	6			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	6			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	005	0	1	04	01	H3916_005_0	6			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	005	0	1	04	01	H3916_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	015	0	1	04	01	H3916_015_0	5			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	5			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	5			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	5			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	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	018	0	1	04	01	H3916_018_0	4			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	4			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	4			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	4			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	018	0	1	04	01	H3916_018_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	022	0	1	04	01	H3916_022_0	5			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	5			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	5			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	5			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	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	024	0	1	04	01	H3916_024_0	6			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	6			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	6			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	6			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	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	032	0	1	04	01	H3916_032_0	4			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	4			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	4			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	4			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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	033	0	1	04	01	H3916_033_0	4			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	4			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	4			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	4			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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	034	1	1	04	01	H3916_034_1	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											92.03	25		25				99.35	25		25												25						25			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
H3916	034	1	1	04	01	H3916_034_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											51.69	50		50				36.34	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
H3916	034	1	1	04	01	H3916_034_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	034	3	1	04	01	H3916_034_3	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											92.03	25		25				99.35	25		25												25						25			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
H3916	034	3	1	04	01	H3916_034_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											51.69	50		50				36.34	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
H3916	034	3	1	04	01	H3916_034_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	034	4	1	04	01	H3916_034_4	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											92.03	25		25				99.35	25		25												25						25			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
H3916	034	4	1	04	01	H3916_034_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											51.69	50		50				36.34	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
H3916	034	4	1	04	01	H3916_034_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	034	5	1	04	01	H3916_034_5	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											92.03	25		25				99.35	25		25												25						25			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
H3916	034	5	1	04	01	H3916_034_5	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											51.69	50		50				36.34	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
H3916	034	5	1	04	01	H3916_034_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	035	1	1	04	01	H3916_035_1	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											96.59	25		25				106.35	25		25												25						25			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
H3916	035	1	1	04	01	H3916_035_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											59.87	50		50				37.41	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
H3916	035	1	1	04	01	H3916_035_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	035	2	1	04	01	H3916_035_2	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											96.59	25		25				106.35	25		25												25						25			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
H3916	035	2	1	04	01	H3916_035_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											59.87	50		50				37.41	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
H3916	035	2	1	04	01	H3916_035_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	035	4	1	04	01	H3916_035_4	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											96.59	25		25				106.35	25		25												25						25			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
H3916	035	4	1	04	01	H3916_035_4	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											59.87	50		50				37.41	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
H3916	035	4	1	04	01	H3916_035_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	036	0	1	04	01	H3916_036_0	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											85.40	25		25				93.48	25		25												25						25			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
H3916	036	0	1	04	01	H3916_036_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											58.56	48		48				45.60	48		48												48						48			48			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
H3916	036	0	1	04	01	H3916_036_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	037	1	1	04	01	H3916_037_1	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	037	1	1	04	01	H3916_037_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	037	1	1	04	01	H3916_037_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	037	2	1	04	01	H3916_037_2	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	037	2	1	04	01	H3916_037_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	037	2	1	04	01	H3916_037_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	037	3	1	04	01	H3916_037_3	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	037	3	1	04	01	H3916_037_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	037	3	1	04	01	H3916_037_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	037	4	1	04	01	H3916_037_4	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	037	4	1	04	01	H3916_037_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	037	4	1	04	01	H3916_037_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	038	0	1	04	01	H3916_038_0	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											97.38	25		25				104.35	25		25												25						25			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
H3916	038	0	1	04	01	H3916_038_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											59.50	50		50				34.91	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
H3916	038	0	1	04	01	H3916_038_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	039	0	1	04	01	H3916_039_0	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											88.06	25		25				100.15	25		25												25						25			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
H3916	039	0	1	04	01	H3916_039_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											62.35	50		50				36.41	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
H3916	039	0	1	04	01	H3916_039_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	041	1	1	04	01	H3916_041_1	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											95.79	25		25				105.34	25		25												25						25			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
H3916	041	1	1	04	01	H3916_041_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											54.30	50		50				33.32	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
H3916	041	1	1	04	01	H3916_041_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	041	2	1	04	01	H3916_041_2	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											95.79	25		25				105.34	25		25												25						25			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
H3916	041	2	1	04	01	H3916_041_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											54.30	50		50				33.32	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
H3916	041	2	1	04	01	H3916_041_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	044	1	1	04	01	H3916_044_1	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											85.91	25		25				95.73	25		25												25						25			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
H3916	044	1	1	04	01	H3916_044_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.94	50		50				42.28	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
H3916	044	1	1	04	01	H3916_044_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	044	2	1	04	01	H3916_044_2	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											85.91	25		25				95.73	25		25												25						25			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
H3916	044	2	1	04	01	H3916_044_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.94	50		50				42.28	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
H3916	044	2	1	04	01	H3916_044_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	044	3	1	04	01	H3916_044_3	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											85.91	25		25				95.73	25		25												25						25			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
H3916	044	3	1	04	01	H3916_044_3	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.94	50		50				42.28	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
H3916	044	3	1	04	01	H3916_044_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	045	1	1	04	01	H3916_045_1	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											86.01	25		25				95.72	25		25												25						25			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
H3916	045	1	1	04	01	H3916_045_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.99	50		50				42.30	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
H3916	045	1	1	04	01	H3916_045_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	045	2	1	04	01	H3916_045_2	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											86.01	25		25				95.72	25		25												25						25			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
H3916	045	2	1	04	01	H3916_045_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.99	50		50				42.30	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
H3916	045	2	1	04	01	H3916_045_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	045	3	1	04	01	H3916_045_3	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											86.01	25		25				95.72	25		25												25						25			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
H3916	045	3	1	04	01	H3916_045_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.99	50		50				42.30	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
H3916	045	3	1	04	01	H3916_045_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	045	4	1	04	01	H3916_045_4	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											86.01	25		25				95.72	25		25												25						25			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
H3916	045	4	1	04	01	H3916_045_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.99	50		50				42.30	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
H3916	045	4	1	04	01	H3916_045_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	046	0	1	04	01	H3916_046_0	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											86.01	25		25				95.72	25		25												25						25			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
H3916	046	0	1	04	01	H3916_046_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											55.99	50		50				42.30	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
H3916	046	0	1	04	01	H3916_046_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	047	1	1	04	01	H3916_047_1	6			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	047	1	1	04	01	H3916_047_1	6			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	047	1	1	04	01	H3916_047_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.86	25		25				102.24	25		25												25						25			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
H3916	047	1	1	04	01	H3916_047_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.66	50		50				34.51	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
H3916	047	1	1	04	01	H3916_047_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	047	2	1	04	01	H3916_047_2	6			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	047	2	1	04	01	H3916_047_2	6			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	047	2	1	04	01	H3916_047_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.86	25		25				102.24	25		25												25						25			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
H3916	047	2	1	04	01	H3916_047_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.66	50		50				34.51	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
H3916	047	2	1	04	01	H3916_047_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	047	3	1	04	01	H3916_047_3	6			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	047	3	1	04	01	H3916_047_3	6			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	047	3	1	04	01	H3916_047_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.86	25		25				102.24	25		25												25						25			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
H3916	047	3	1	04	01	H3916_047_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.66	50		50				34.51	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
H3916	047	3	1	04	01	H3916_047_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	048	1	1	04	01	H3916_048_1	6			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	048	1	1	04	01	H3916_048_1	6			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	048	1	1	04	01	H3916_048_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	048	1	1	04	01	H3916_048_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	048	1	1	04	01	H3916_048_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	048	2	1	04	01	H3916_048_2	6			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	048	2	1	04	01	H3916_048_2	6			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	048	2	1	04	01	H3916_048_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	048	2	1	04	01	H3916_048_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	048	2	1	04	01	H3916_048_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	048	3	1	04	01	H3916_048_3	6			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	048	3	1	04	01	H3916_048_3	6			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	048	3	1	04	01	H3916_048_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	048	3	1	04	01	H3916_048_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	048	3	1	04	01	H3916_048_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	049	1	1	04	01	H3916_049_1	6			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	049	1	1	04	01	H3916_049_1	6			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	049	1	1	04	01	H3916_049_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											84.81	21		21				92.07	21		21												21						21			21			21								Preferred Generic, 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	049	1	1	04	01	H3916_049_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											42.44	25		25				27.06	25		25												25						25			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
H3916	049	1	1	04	01	H3916_049_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	049	2	1	04	01	H3916_049_2	6			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	049	2	1	04	01	H3916_049_2	6			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	049	2	1	04	01	H3916_049_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											84.81	21		21				92.07	21		21												21						21			21			21								Preferred Generic, 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	049	2	1	04	01	H3916_049_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											42.44	25		25				27.06	25		25												25						25			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
H3916	049	2	1	04	01	H3916_049_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	049	3	1	04	01	H3916_049_3	6			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	049	3	1	04	01	H3916_049_3	6			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	049	3	1	04	01	H3916_049_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											84.81	21		21				92.07	21		21												21						21			21			21								Preferred Generic, 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	049	3	1	04	01	H3916_049_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											42.44	25		25				27.06	25		25												25						25			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
H3916	049	3	1	04	01	H3916_049_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	050	1	1	04	01	H3916_050_1	6			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	050	1	1	04	01	H3916_050_1	6			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	050	1	1	04	01	H3916_050_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	050	1	1	04	01	H3916_050_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	050	1	1	04	01	H3916_050_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	050	2	1	04	01	H3916_050_2	6			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	050	2	1	04	01	H3916_050_2	6			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	050	2	1	04	01	H3916_050_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	050	2	1	04	01	H3916_050_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	050	2	1	04	01	H3916_050_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	050	3	1	04	01	H3916_050_3	6			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	050	3	1	04	01	H3916_050_3	6			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	050	3	1	04	01	H3916_050_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	050	3	1	04	01	H3916_050_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	050	3	1	04	01	H3916_050_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	050	4	1	04	01	H3916_050_4	6			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	050	4	1	04	01	H3916_050_4	6			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	050	4	1	04	01	H3916_050_4	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	050	4	1	04	01	H3916_050_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	050	4	1	04	01	H3916_050_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	051	0	1	04	01	H3916_051_0	6			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	051	0	1	04	01	H3916_051_0	6			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	051	0	1	04	01	H3916_051_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.75	25		25				102.23	25		25												25						25			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
H3916	051	0	1	04	01	H3916_051_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.69	50		50				34.51	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
H3916	051	0	1	04	01	H3916_051_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	052	1	1	04	01	H3916_052_1	5			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	052	1	1	04	01	H3916_052_1	5			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	052	1	1	04	01	H3916_052_1	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	052	1	1	04	01	H3916_052_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	052	1	1	04	01	H3916_052_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	052	2	1	04	01	H3916_052_2	5			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	052	2	1	04	01	H3916_052_2	5			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	052	2	1	04	01	H3916_052_2	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	052	2	1	04	01	H3916_052_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	052	2	1	04	01	H3916_052_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	052	3	1	04	01	H3916_052_3	5			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	052	3	1	04	01	H3916_052_3	5			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	052	3	1	04	01	H3916_052_3	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	052	3	1	04	01	H3916_052_3	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	052	3	1	04	01	H3916_052_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	052	4	1	04	01	H3916_052_4	5			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	052	4	1	04	01	H3916_052_4	5			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	052	4	1	04	01	H3916_052_4	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	052	4	1	04	01	H3916_052_4	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	052	4	1	04	01	H3916_052_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	053	0	1	04	01	H3916_053_0	5			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	053	0	1	04	01	H3916_053_0	5			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	053	0	1	04	01	H3916_053_0	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.78	25		25				102.07	25		25												25						25			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
H3916	053	0	1	04	01	H3916_053_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.65	50		50				34.49	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
H3916	053	0	1	04	01	H3916_053_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	054	0	1	04	01	H3916_054_0	6			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	054	0	1	04	01	H3916_054_0	6			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																								
H3916	054	0	1	04	01	H3916_054_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.90	25		25				102.08	25		25												25						25			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
H3916	054	0	1	04	01	H3916_054_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.61	50		50				34.48	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
H3916	054	0	1	04	01	H3916_054_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3916	055	0	1	04	01	H3916_055_0	6			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	055	0	1	04	01	H3916_055_0	6			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																								
H3916	055	0	1	04	01	H3916_055_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.90	25		25				102.08	25		25												25						25			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
H3916	055	0	1	04	01	H3916_055_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.61	50		50				34.48	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
H3916	055	0	1	04	01	H3916_055_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3923	013	0	1	04	01	H3923_013_0	4			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				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	4			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					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	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.42	38	38	38				99.42	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
H3923	013	0	1	04	01	H3923_013_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											653.10	33						672.87	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
H3923	017	0	1	04	01	H3923_017_0	4			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				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	017	0	1	04	01	H3923_017_0	4			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					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	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	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	200.00	300.00				100.00	200.00	300.00				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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											654.72	33						700.00	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
H3923	028	0	1	04	01	H3923_028_0	4			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				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	028	0	1	04	01	H3923_028_0	4			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					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	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.24	20	20	20				43.64	20	20	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	70.00	105.00	35.00		35.00
H3923	028	0	1	04	01	H3923_028_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.37	50	50	50				94.80	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
H3923	028	0	1	04	01	H3923_028_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											500.58	28						472.13	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
H3923	029	0	1	04	01	H3923_029_0	4			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				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	029	0	1	04	01	H3923_029_0	4			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					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	029	0	1	04	01	H3923_029_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.21	20	20	20				42.34	20	20	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	70.00	105.00	35.00		35.00
H3923	029	0	1	04	01	H3923_029_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.36	50	50	50				87.02	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
H3923	029	0	1	04	01	H3923_029_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											396.52	28						611.81	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
H3923	030	0	1	04	01	H3923_030_0	4			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				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	4			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					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
H3923	030	0	1	04	01	H3923_030_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.42	20	20	20				26.57	20	20	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	70.00	105.00	35.00		35.00
H3923	030	0	1	04	01	H3923_030_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.93	50	50	50				82.78	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
H3923	030	0	1	04	01	H3923_030_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											605.21	31						616.92	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
H3923	031	0	1	04	01	H3923_031_0	4			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				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	031	0	1	04	01	H3923_031_0	4			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					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	031	0	1	04	01	H3923_031_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.58	20	20	20				38.23	20	20	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	70.00	105.00	35.00		35.00
H3923	031	0	1	04	01	H3923_031_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.67	50	50	50				80.64	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
H3923	031	0	1	04	01	H3923_031_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											656.33	28						606.08	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
H3923	032	0	1	04	01	H3923_032_0	4			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				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	032	0	1	04	01	H3923_032_0	4			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					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	032	0	1	04	01	H3923_032_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.10	20	20	20				42.48	20	20	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	70.00	105.00	35.00		35.00
H3923	032	0	1	04	01	H3923_032_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.31	50	50	50				84.15	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
H3923	032	0	1	04	01	H3923_032_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.65	28						582.99	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
H3923	033	0	1	04	01	H3923_033_0	4			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				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	033	0	1	04	01	H3923_033_0	4			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					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	033	0	1	04	01	H3923_033_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											42.15	20	20	20				43.97	20	20	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	70.00	105.00	35.00		35.00
H3923	033	0	1	04	01	H3923_033_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.22	50	50	50				87.34	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
H3923	033	0	1	04	01	H3923_033_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											636.84	28						573.39	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
H3923	034	0	1	04	01	H3923_034_0	4			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				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	4			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					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
H3923	034	0	1	04	01	H3923_034_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											28.43	20	20	20				27.95	20	20	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	70.00	105.00	35.00		35.00
H3923	034	0	1	04	01	H3923_034_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											79.67	50	50	50				93.18	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
H3923	034	0	1	04	01	H3923_034_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											794.95	31						616.12	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
H3923	035	0	1	04	01	H3923_035_0	4			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				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	4			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					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
H3923	035	0	1	04	01	H3923_035_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.67	20	20	20				28.14	20	20	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	70.00	105.00	35.00		35.00
H3923	035	0	1	04	01	H3923_035_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.53	50	50	50				88.65	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
H3923	035	0	1	04	01	H3923_035_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											498.92	31						529.05	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
H3923	038	0	1	04	01	H3923_038_0	4			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				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	038	0	1	04	01	H3923_038_0	4			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					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
H3923	038	0	1	04	01	H3923_038_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											28.39	20	20	20				29.27	20	20	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	70.00	105.00	35.00		35.00
H3923	038	0	1	04	01	H3923_038_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											61.04	45	45	45				63.74	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
H3923	038	0	1	04	01	H3923_038_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											683.21	33						592.49	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
H3923	039	0	1	04	01	H3923_039_0	4			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				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	039	0	1	04	01	H3923_039_0	4			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					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
H3923	039	0	1	04	01	H3923_039_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											28.54	20	20	20				29.47	20	20	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	70.00	105.00	35.00		35.00
H3923	039	0	1	04	01	H3923_039_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											61.19	45	45	45				63.94	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
H3923	039	0	1	04	01	H3923_039_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											697.11	33						586.57	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
H3923	040	0	1	04	01	H3923_040_0	4			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				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	040	0	1	04	01	H3923_040_0	4			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					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
H3923	040	0	1	04	01	H3923_040_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.26	20	20	20				26.40	20	20	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	70.00	105.00	35.00		35.00
H3923	040	0	1	04	01	H3923_040_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											62.31	45	45	45				60.52	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
H3923	040	0	1	04	01	H3923_040_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											650.47	33						640.18	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
H3924	059	21	1	04	01	H3924_059_21	3			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, Select Care Drugs																								
H3924	059	21	1	04	01	H3924_059_21	3			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, Select Care Drugs																								
H3924	059	21	1	04	01	H3924_059_21	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				113.64	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3924	059	21	1	04	01	H3924_059_21	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.21	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3924	059	21	1	04	01	H3924_059_21	3			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																								
H3924	059	21	1	04	01	H3924_059_21	3			Select Care Drugs	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, Select Care Drugs																								
H3924	059	22	1	04	01	H3924_059_22	3			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, Select Care Drugs																								
H3924	059	22	1	04	01	H3924_059_22	3			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, Select Care Drugs																								
H3924	059	22	1	04	01	H3924_059_22	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				113.64	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3924	059	22	1	04	01	H3924_059_22	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.21	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3924	059	22	1	04	01	H3924_059_22	3			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																								
H3924	059	22	1	04	01	H3924_059_22	3			Select Care Drugs	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, Select Care Drugs																								
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, Select Care Drugs																								
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	10.00	20.00	25.00																			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, Select Care Drugs																								
H3924	062	21	1	04	01	H3924_062_21	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				119.22	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				83.20	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3924	062	21	1	04	01	H3924_062_21	4			Select Care Drugs	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, Select Care Drugs																								
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, Select Care Drugs																								
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	10.00	20.00	25.00																			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, Select Care Drugs																								
H3924	062	22	1	04	01	H3924_062_22	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				119.22	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				83.20	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3924	062	22	1	04	01	H3924_062_22	4			Select Care Drugs	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, Select Care Drugs																								
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, Select Care Drugs																								
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	10.00	20.00	25.00																			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, Select Care Drugs																								
H3924	062	23	1	04	01	H3924_062_23	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				119.22	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				83.20	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3924	062	23	1	04	01	H3924_062_23	4			Select Care Drugs	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, Select Care Drugs																								
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, Select Care Drugs																								
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	10.00	20.00	25.00																			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, Select Care Drugs																								
H3924	062	24	1	04	01	H3924_062_24	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				119.22	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				83.20	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3924	062	24	1	04	01	H3924_062_24	4			Select Care Drugs	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, Select Care Drugs																								
H3924	065	0	1	04	01	H3924_065_0	3			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, Select Care Drugs																								
H3924	065	0	1	04	01	H3924_065_0	3			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, Select Care Drugs																								
H3924	065	0	1	04	01	H3924_065_0	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				112.41	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3924	065	0	1	04	01	H3924_065_0	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				86.82	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3924	065	0	1	04	01	H3924_065_0	3			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																								
H3924	065	0	1	04	01	H3924_065_0	3			Select Care Drugs	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, Select Care Drugs																								
H3928	001	0	1	01	01	H3928_001_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3928	001	0	1	01	01	H3928_001_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3928	001	0	1	01	01	H3928_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											79.29	24	24	24				100.14	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
H3928	001	0	1	01	01	H3928_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											42.66	25	25	25				33.51	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
H3928	001	0	1	01	01	H3928_001_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.66	25						809.28	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
H3931	004	0	1	02	01	H3931_004_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	004	0	1	02	01	H3931_004_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	004	0	1	02	01	H3931_004_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.72	24	24	24				104.63	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
H3931	004	0	1	02	01	H3931_004_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											39.95	25	25	25				40.27	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
H3931	004	0	1	02	01	H3931_004_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											776.39	25						927.89	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
H3931	064	0	1	02	01	H3931_064_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	064	0	1	02	01	H3931_064_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	064	0	1	02	01	H3931_064_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.52	24	24	24				106.96	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
H3931	064	0	1	02	01	H3931_064_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.67	25	25	25				41.80	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
H3931	064	0	1	02	01	H3931_064_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											907.01	25						928.33	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
H3931	091	0	1	02	01	H3931_091_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	091	0	1	02	01	H3931_091_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	091	0	1	02	01	H3931_091_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.92	24	24	24				113.17	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
H3931	091	0	1	02	01	H3931_091_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.12	25	25	25				38.18	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
H3931	091	0	1	02	01	H3931_091_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											773.51	25						767.05	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
H3931	092	0	1	02	01	H3931_092_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	092	0	1	02	01	H3931_092_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	092	0	1	02	01	H3931_092_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.09	24	24	24				116.41	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
H3931	092	0	1	02	01	H3931_092_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.27	25	25	25				37.81	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
H3931	092	0	1	02	01	H3931_092_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											911.98	25						774.12	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
H3931	094	0	1	02	01	H3931_094_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	094	0	1	02	01	H3931_094_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	094	0	1	02	01	H3931_094_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.70	24	24	24				109.51	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
H3931	094	0	1	02	01	H3931_094_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.35	25	25	25				45.24	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
H3931	094	0	1	02	01	H3931_094_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.09	25						706.89	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
H3931	095	0	1	02	01	H3931_095_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	095	0	1	02	01	H3931_095_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	095	0	1	02	01	H3931_095_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.91	25	25	25				92.61	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
H3931	095	0	1	02	01	H3931_095_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.95	35	35	35				41.32	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
H3931	095	0	1	02	01	H3931_095_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1008.57	33						1176.52	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
H3931	097	0	1	02	01	H3931_097_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	097	0	1	02	01	H3931_097_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	097	0	1	02	01	H3931_097_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.26	25	25	25				106.62	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
H3931	097	0	1	02	01	H3931_097_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.47	26	26	26				35.75	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1151.20	30						896.50	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	099	0	1	02	01	H3931_099_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	099	0	1	02	01	H3931_099_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	099	0	1	02	01	H3931_099_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.33	25	25	25				90.26	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
H3931	099	0	1	02	01	H3931_099_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											38.49	35	35	35				29.75	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
H3931	099	0	1	02	01	H3931_099_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1046.58	33						915.73	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	100	0	1	02	01	H3931_100_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	100	0	1	02	01	H3931_100_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	100	0	1	02	01	H3931_100_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.76	25	25	25				85.66	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
H3931	100	0	1	02	01	H3931_100_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.25	35	35	35				33.47	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
H3931	100	0	1	02	01	H3931_100_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1030.07	33						914.39	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	101	0	1	02	01	H3931_101_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	101	0	1	02	01	H3931_101_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	101	0	1	02	01	H3931_101_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.21	25	25	25				89.48	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
H3931	101	0	1	02	01	H3931_101_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.03	35	35	35				27.43	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
H3931	101	0	1	02	01	H3931_101_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											939.86	33						1080.18	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
H3931	102	0	1	01	01	H3931_102_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	102	0	1	01	01	H3931_102_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	102	0	1	01	01	H3931_102_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.46	24	24	24				114.83	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
H3931	102	0	1	01	01	H3931_102_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.06	25	25	25				40.49	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
H3931	102	0	1	01	01	H3931_102_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											710.15	25						787.84	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
H3931	107	0	1	02	01	H3931_107_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	107	0	1	02	01	H3931_107_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	107	0	1	02	01	H3931_107_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.07	25	25	25				87.99	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
H3931	107	0	1	02	01	H3931_107_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.31	35	35	35				30.87	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
H3931	107	0	1	02	01	H3931_107_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1171.80	33						1021.66	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
H3931	108	0	1	01	01	H3931_108_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	108	0	1	01	01	H3931_108_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	108	0	1	01	01	H3931_108_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.85	25	25	25				86.34	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
H3931	108	0	1	01	01	H3931_108_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.03	35	35	35				31.38	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
H3931	108	0	1	01	01	H3931_108_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											956.80	33						1182.83	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
H3931	109	0	1	02	01	H3931_109_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	109	0	1	02	01	H3931_109_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	109	0	1	02	01	H3931_109_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.09	25	25	25				84.70	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
H3931	109	0	1	02	01	H3931_109_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.39	35	35	35				31.64	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
H3931	109	0	1	02	01	H3931_109_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1116.84	33						1167.75	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
H3931	126	0	1	02	01	H3931_126_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	126	0	1	02	01	H3931_126_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	126	0	1	02	01	H3931_126_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.23	24	24	24				102.44	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
H3931	126	0	1	02	01	H3931_126_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.41	25	25	25				32.07	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
H3931	126	0	1	02	01	H3931_126_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											602.43	25						714.59	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
H3931	129	0	1	02	01	H3931_129_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	129	0	1	02	01	H3931_129_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	129	0	1	02	01	H3931_129_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.50	24	24	24				103.68	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
H3931	129	0	1	02	01	H3931_129_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.02	25	25	25				38.66	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
H3931	129	0	1	02	01	H3931_129_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											852.60	25						789.24	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
H3931	143	0	1	02	01	H3931_143_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	143	0	1	02	01	H3931_143_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	143	0	1	02	01	H3931_143_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.70	25	25	25				119.99	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
H3931	143	0	1	02	01	H3931_143_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.26	26	26	26				37.25	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1106.19	30						1023.78	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
H3931	146	0	1	02	01	H3931_146_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	146	0	1	02	01	H3931_146_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	146	0	1	02	01	H3931_146_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.47	24	24	24				106.85	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
H3931	146	0	1	02	01	H3931_146_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.97	25	25	25				36.75	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
H3931	146	0	1	02	01	H3931_146_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											928.86	25						765.16	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
H3931	147	0	1	02	01	H3931_147_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	147	0	1	02	01	H3931_147_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	147	0	1	02	01	H3931_147_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.10	24	24	24				106.44	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
H3931	147	0	1	02	01	H3931_147_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.29	25	25	25				37.66	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
H3931	147	0	1	02	01	H3931_147_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											871.33	25						868.18	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
H3931	148	0	1	02	01	H3931_148_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	148	0	1	02	01	H3931_148_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	148	0	1	02	01	H3931_148_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.32	24	24	24				105.95	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
H3931	148	0	1	02	01	H3931_148_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.61	25	25	25				38.90	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
H3931	148	0	1	02	01	H3931_148_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											864.98	25						786.46	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
H3931	151	0	1	02	01	H3931_151_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	151	0	1	02	01	H3931_151_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	151	0	1	02	01	H3931_151_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.00	25	25	25				82.05	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
H3931	151	0	1	02	01	H3931_151_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.27	35	35	35				36.68	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
H3931	151	0	1	02	01	H3931_151_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1512.20	33						1035.59	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
H3931	152	0	1	02	01	H3931_152_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	152	0	1	02	01	H3931_152_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	152	0	1	02	01	H3931_152_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.32	24	24	24				109.00	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
H3931	152	0	1	02	01	H3931_152_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.28	25	25	25				37.11	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
H3931	152	0	1	02	01	H3931_152_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											902.38	25						643.15	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
H3931	153	0	1	02	01	H3931_153_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	153	0	1	02	01	H3931_153_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	153	0	1	02	01	H3931_153_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.34	24	24	24				111.30	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
H3931	153	0	1	02	01	H3931_153_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.67	25	25	25				37.29	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
H3931	153	0	1	02	01	H3931_153_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											862.23	25						692.46	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
H3931	154	0	1	02	01	H3931_154_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	154	0	1	02	01	H3931_154_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	154	0	1	02	01	H3931_154_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.07	24	24	24				109.26	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
H3931	154	0	1	02	01	H3931_154_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.76	25	25	25				35.69	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
H3931	154	0	1	02	01	H3931_154_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											812.89	25						723.24	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
H3931	157	0	1	02	01	H3931_157_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	157	0	1	02	01	H3931_157_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	157	0	1	02	01	H3931_157_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.17	24	24	24				100.65	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
H3931	157	0	1	02	01	H3931_157_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.63	25	25	25				40.83	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
H3931	157	0	1	02	01	H3931_157_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.36	25						703.67	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
H3931	158	0	1	02	01	H3931_158_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	158	0	1	02	01	H3931_158_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	158	0	1	02	01	H3931_158_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.09	25	25	25				79.93	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
H3931	158	0	1	02	01	H3931_158_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.53	35	35	35				29.43	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
H3931	158	0	1	02	01	H3931_158_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											984.24	33						990.36	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
H3931	160	0	1	02	01	H3931_160_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	160	0	1	02	01	H3931_160_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	160	0	1	02	01	H3931_160_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.33	24	24	24				100.89	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
H3931	160	0	1	02	01	H3931_160_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.57	25	25	25				40.53	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
H3931	160	0	1	02	01	H3931_160_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											714.31	25						704.23	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
H3931	162	0	1	02	01	H3931_162_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	162	0	1	02	01	H3931_162_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	162	0	1	02	01	H3931_162_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.87	25	25	25				100.85	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
H3931	162	0	1	02	01	H3931_162_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.56	26	26	26				34.25	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											923.00	30						901.03	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	166	0	1	02	01	H3931_166_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	166	0	1	02	01	H3931_166_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	166	0	1	02	01	H3931_166_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.56	24	24	24				107.75	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
H3931	166	0	1	02	01	H3931_166_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.22	25	25	25				43.87	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
H3931	166	0	1	02	01	H3931_166_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											769.04	25						759.19	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
H3931	169	0	1	02	01	H3931_169_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	169	0	1	02	01	H3931_169_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	169	0	1	02	01	H3931_169_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.69	24	24	24				107.84	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
H3931	169	0	1	02	01	H3931_169_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.11	25	25	25				43.41	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
H3931	169	0	1	02	01	H3931_169_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											771.01	25						759.01	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
H3931	176	0	1	02	01	H3931_176_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	176	0	1	02	01	H3931_176_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	176	0	1	02	01	H3931_176_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.65	24	24	24				107.77	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
H3931	176	0	1	02	01	H3931_176_0	3			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	25	25	25				43.37	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
H3931	176	0	1	02	01	H3931_176_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											772.77	25						759.27	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
H3931	177	0	1	02	01	H3931_177_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	177	0	1	02	01	H3931_177_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	177	0	1	02	01	H3931_177_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.65	24	24	24				107.77	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
H3931	177	0	1	02	01	H3931_177_0	3			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	25	25	25				43.36	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
H3931	177	0	1	02	01	H3931_177_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											772.77	25						758.99	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
H3931	178	0	1	02	01	H3931_178_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	178	0	1	02	01	H3931_178_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3931	178	0	1	02	01	H3931_178_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.00	25	25	25				107.50	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
H3931	178	0	1	02	01	H3931_178_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.82	26	26	26				43.70	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	178	0	1	02	01	H3931_178_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											922.68	30						912.98	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
H3931	185	0	1	02	01	H3931_185_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	185	0	1	02	01	H3931_185_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3931	185	0	1	02	01	H3931_185_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.41	22	22	22				41.97	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	185	0	1	02	01	H3931_185_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.96	25	25	25				45.90	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
H3931	185	0	1	02	01	H3931_185_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											359.03	25						313.32	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
H3949	024	0	1	01	01	H3949_024_0	4			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, 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	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H3949	024	0	1	01	01	H3949_024_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											644.66	33						480.37	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	4			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	4			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
H3949	030	0	1	01	01	H3949_030_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H3949	030	0	1	01	01	H3949_030_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											850.18	33						747.55	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
H3949	031	0	1	01	01	H3949_031_0	4			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
H3949	031	0	1	01	01	H3949_031_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H3949	031	0	1	01	01	H3949_031_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											822.89	33						763.16	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
H3949	032	0	1	01	01	H3949_032_0	4			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
H3949	032	0	1	01	01	H3949_032_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H3949	032	0	1	01	01	H3949_032_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											717.91	33						567.30	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
H3949	035	0	1	01	01	H3949_035_0	4			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
H3949	035	0	1	01	01	H3949_035_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H3949	035	0	1	01	01	H3949_035_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											787.74	33						745.47	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
H3949	045	0	1	01	01	H3949_045_0	4			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
H3949	045	0	1	01	01	H3949_045_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H3949	045	0	1	01	01	H3949_045_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											714.59	33						663.85	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
H3949	046	0	1	01	01	H3949_046_0	4			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
H3949	046	0	1	01	01	H3949_046_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H3949	046	0	1	01	01	H3949_046_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											852.03	33						752.95	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
H3949	047	0	1	01	01	H3949_047_0	4			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
H3949	047	0	1	01	01	H3949_047_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	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
H3949	047	0	1	01	01	H3949_047_0	4			Preferred Brand	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	047	0	1	01	01	H3949_047_0	4			Non-Preferred Drug	4	11	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
H3949	047	0	1	01	01	H3949_047_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											725.75	33						634.42	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
H3949	048	0	1	01	01	H3949_048_0	4			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
H3949	048	0	1	01	01	H3949_048_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	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
H3949	048	0	1	01	01	H3949_048_0	4			Preferred Brand	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	048	0	1	01	01	H3949_048_0	4			Non-Preferred Drug	4	11	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
H3949	048	0	1	01	01	H3949_048_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											902.99	33						774.29	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
H3949	049	0	1	01	01	H3949_049_0	4			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
H3949	049	0	1	01	01	H3949_049_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	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
H3949	049	0	1	01	01	H3949_049_0	4			Preferred Brand	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	049	0	1	01	01	H3949_049_0	4			Non-Preferred Drug	4	11	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
H3949	049	0	1	01	01	H3949_049_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											748.93	33						680.73	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	050	0	1	01	01	H3949_050_0	4			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
H3949	050	0	1	01	01	H3949_050_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	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
H3949	050	0	1	01	01	H3949_050_0	4			Preferred Brand	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	050	0	1	01	01	H3949_050_0	4			Non-Preferred Drug	4	11	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
H3949	050	0	1	01	01	H3949_050_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											902.41	33						770.43	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
H3949	052	0	1	01	01	H3949_052_0	4			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
H3949	052	0	1	01	01	H3949_052_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					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	052	0	1	01	01	H3949_052_0	4			Preferred Brand	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	052	0	1	01	01	H3949_052_0	4			Non-Preferred Drug	4	11	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
H3949	052	0	1	01	01	H3949_052_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											852.03	33						752.95	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
H3949	053	0	1	01	01	H3949_053_0	4			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
H3949	053	0	1	01	01	H3949_053_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					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	053	0	1	01	01	H3949_053_0	4			Preferred Brand	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	053	0	1	01	01	H3949_053_0	4			Non-Preferred Drug	4	11	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
H3949	053	0	1	01	01	H3949_053_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											852.03	33						752.95	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
H3952	020	0	1	01	01	H3952_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								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	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					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																								
H3952	020	0	1	01	01	H3952_020_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											66.00	25	25	25				70.00	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	70.00	70.00				35.00		35.00
H3952	020	0	1	01	01	H3952_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											42.00	50	50	50				40.00	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	70.00				35.00		35.00
H3952	020	0	1	01	01	H3952_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												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	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																								
H3952	045	0	1	01	01	H3952_045_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					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																								
H3952	045	0	1	01	01	H3952_045_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											71.00	25	25	25				70.00	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	70.00	70.00				35.00		35.00
H3952	045	0	1	01	01	H3952_045_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											36.00	50	50	50				36.00	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	70.00				35.00		35.00
H3952	045	0	1	01	01	H3952_045_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
H3952	049	0	1	01	01	H3952_049_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																								
H3952	049	0	1	01	01	H3952_049_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					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																								
H3952	049	0	1	01	01	H3952_049_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											67.00	25	25	25				67.00	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	70.00	70.00				35.00		35.00
H3952	049	0	1	01	01	H3952_049_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											42.00	50	50	50				38.00	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	70.00				35.00		35.00
H3952	049	0	1	01	01	H3952_049_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
H3952	051	0	1	01	01	H3952_051_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																								
H3952	051	0	1	01	01	H3952_051_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					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																								
H3952	051	0	1	01	01	H3952_051_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											66.00	25	25	25				70.00	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	70.00	70.00				35.00		35.00
H3952	051	0	1	01	01	H3952_051_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											37.00	50	50	50				36.00	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	70.00				35.00		35.00
H3952	051	0	1	01	01	H3952_051_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
H3952	053	0	1	02	01	H3952_053_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																								
H3952	053	0	1	02	01	H3952_053_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					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																								
H3952	053	0	1	02	01	H3952_053_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											75.00	25	25	25				71.00	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	70.00	70.00				35.00		35.00
H3952	053	0	1	02	01	H3952_053_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											43.00	50	50	50				38.00	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	70.00				35.00		35.00
H3952	053	0	1	02	01	H3952_053_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
H3952	054	0	1	02	01	H3952_054_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																								
H3952	054	0	1	02	01	H3952_054_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					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																								
H3952	054	0	1	02	01	H3952_054_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											73.00	25	25	25				72.00	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	70.00	70.00				35.00		35.00
H3952	054	0	1	02	01	H3952_054_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											41.00	50	50	50				37.00	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	70.00				35.00		35.00
H3952	054	0	1	02	01	H3952_054_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
H3952	055	0	1	01	01	H3952_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								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	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					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																								
H3952	055	0	1	01	01	H3952_055_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											76.00	25	25	25				73.00	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	70.00	70.00				35.00		35.00
H3952	055	0	1	01	01	H3952_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											44.00	50	50	50				36.00	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	70.00				35.00		35.00
H3952	055	0	1	01	01	H3952_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												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	060	0	1	02	01	H3952_060_0	7			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					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																								
H3952	060	0	1	02	01	H3952_060_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					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																								
H3952	060	0	1	02	01	H3952_060_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											70.00	25	25	25				71.00	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	70.00	70.00				35.00		35.00
H3952	060	0	1	02	01	H3952_060_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											42.00	50	50	50				38.00	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	70.00				35.00		35.00
H3952	060	0	1	02	01	H3952_060_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
H3954	157	21	1	01	01	H3954_157_21	3			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, Select Care Drugs																								
H3954	157	21	1	01	01	H3954_157_21	3			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, Select Care Drugs																								
H3954	157	21	1	01	01	H3954_157_21	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				111.71	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	157	21	1	01	01	H3954_157_21	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				81.35	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	157	21	1	01	01	H3954_157_21	3			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																								
H3954	157	21	1	01	01	H3954_157_21	3			Select Care Drugs	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, Select Care Drugs																								
H3954	157	22	1	01	01	H3954_157_22	3			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, Select Care Drugs																								
H3954	157	22	1	01	01	H3954_157_22	3			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, Select Care Drugs																								
H3954	157	22	1	01	01	H3954_157_22	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				111.71	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	157	22	1	01	01	H3954_157_22	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				81.35	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	157	22	1	01	01	H3954_157_22	3			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																								
H3954	157	22	1	01	01	H3954_157_22	3			Select Care Drugs	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, Select Care Drugs																								
H3954	157	23	1	01	01	H3954_157_23	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, Select Care Drugs																								
H3954	157	23	1	01	01	H3954_157_23	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, Select Care Drugs																								
H3954	157	23	1	01	01	H3954_157_23	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				111.71	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	157	23	1	01	01	H3954_157_23	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				81.35	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	157	23	1	01	01	H3954_157_23	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																								
H3954	157	23	1	01	01	H3954_157_23	4			Select Care Drugs	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, Select Care Drugs																								
H3954	158	13	1	01	01	H3954_158_13	3			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, Select Care Drugs																								
H3954	158	13	1	01	01	H3954_158_13	3			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, Select Care Drugs																								
H3954	158	13	1	01	01	H3954_158_13	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				117.77	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	158	13	1	01	01	H3954_158_13	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				85.67	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	158	13	1	01	01	H3954_158_13	3			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																								
H3954	158	13	1	01	01	H3954_158_13	3			Select Care Drugs	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, Select Care Drugs																								
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, Select Care Drugs																								
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, Select Care Drugs																								
H3954	158	14	1	01	01	H3954_158_14	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				117.77	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				85.67	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3954	158	14	1	01	01	H3954_158_14	4			Select Care Drugs	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, Select Care Drugs																								
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, Select Care Drugs																								
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, Select Care Drugs																								
H3954	160	0	1	01	01	H3954_160_0	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				119.36	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				90.86	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				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	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3954	160	0	1	01	01	H3954_160_0	4			Select Care Drugs	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, Select Care Drugs																								
H3954	161	0	1	01	01	H3954_161_0	3			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, Select Care Drugs																								
H3954	161	0	1	01	01	H3954_161_0	3			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, Select Care Drugs																								
H3954	161	0	1	01	01	H3954_161_0	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				119.87	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	161	0	1	01	01	H3954_161_0	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				89.96	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	52.50	52.50				35.00		35.00
H3954	161	0	1	01	01	H3954_161_0	3			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																								
H3954	161	0	1	01	01	H3954_161_0	3			Select Care Drugs	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, Select Care Drugs																								
H3954	163	0	1	01	01	H3954_163_0	5			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, Select Care Drugs																								
H3954	163	0	1	01	01	H3954_163_0	5			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, Select Care Drugs																								
H3954	163	0	1	01	01	H3954_163_0	5			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				117.89	25	25	25																		10	10	10															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										25.00	50.00	75.00				25.00	37.50	37.50				25.00		25.00
H3954	163	0	1	01	01	H3954_163_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				85.91	50	50	50																		30	30	30															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										25.00	50.00	75.00				25.00	37.50	37.50				25.00		25.00
H3954	163	0	1	01	01	H3954_163_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																								
H3954	163	0	1	01	01	H3954_163_0	5			Select Care Drugs	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, Select Care Drugs																								
H3957	031	0	1	02	01	H3957_031_0	6			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	6			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	6			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	6			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	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	039	0	1	01	01	H3957_039_0	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											86.10	25		25				95.73	25		25												25						25			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
H3957	039	0	1	01	01	H3957_039_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.47	50		50				41.57	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
H3957	039	0	1	01	01	H3957_039_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	042	1	1	01	01	H3957_042_1	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											90.58	25		25				99.73	25		25												25						25			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
H3957	042	1	1	01	01	H3957_042_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.90	50		50				35.56	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
H3957	042	1	1	01	01	H3957_042_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	042	2	1	01	01	H3957_042_2	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											90.58	25		25				99.73	25		25												25						25			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
H3957	042	2	1	01	01	H3957_042_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.90	50		50				35.56	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
H3957	042	2	1	01	01	H3957_042_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	042	4	1	01	01	H3957_042_4	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											90.58	25		25				99.73	25		25												25						25			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
H3957	042	4	1	01	01	H3957_042_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.90	50		50				35.56	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
H3957	042	4	1	01	01	H3957_042_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	042	5	1	01	01	H3957_042_5	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											90.58	25		25				99.73	25		25												25						25			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
H3957	042	5	1	01	01	H3957_042_5	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.90	50		50				35.56	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
H3957	042	5	1	01	01	H3957_042_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	042	6	1	01	01	H3957_042_6	6			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	6	1	01	01	H3957_042_6	6			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	6	1	01	01	H3957_042_6	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											90.58	25		25				99.73	25		25												25						25			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
H3957	042	6	1	01	01	H3957_042_6	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.90	50		50				35.56	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
H3957	042	6	1	01	01	H3957_042_6	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	044	1	1	02	01	H3957_044_1	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	1	1	02	01	H3957_044_1	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	1	1	02	01	H3957_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					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	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	1	1	02	01	H3957_044_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							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												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	045	1	1	02	01	H3957_045_1	6			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	6			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	6			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	6			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	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																								
H3957	045	2	1	02	01	H3957_045_2	6			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	6			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	6			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	6			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	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																								
H3957	046	1	1	02	01	H3957_046_1	7			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	7			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	7			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	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																					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	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																								
H3957	046	2	1	02	01	H3957_046_2	7			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	7			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	7			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	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																					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	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																								
H3957	047	1	1	01	01	H3957_047_1	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.16	25		25				104.01	25		25												25						25			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
H3957	047	1	1	01	01	H3957_047_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											62.49	50		50				36.65	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
H3957	047	1	1	01	01	H3957_047_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	047	2	1	01	01	H3957_047_2	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.16	25		25				104.01	25		25												25						25			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
H3957	047	2	1	01	01	H3957_047_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											62.49	50		50				36.65	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
H3957	047	2	1	01	01	H3957_047_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	047	3	1	01	01	H3957_047_3	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											94.16	25		25				104.01	25		25												25						25			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
H3957	047	3	1	01	01	H3957_047_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											62.49	50		50				36.65	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
H3957	047	3	1	01	01	H3957_047_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3957	048	0	1	01	01	H3957_048_0	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.63	18		18				72.78	18		18												18						18			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
H3957	048	0	1	01	01	H3957_048_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.36	50		50				31.38	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
H3957	048	0	1	01	01	H3957_048_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3959	001	0	1	02	01	H3959_001_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	001	0	1	02	01	H3959_001_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	001	0	1	02	01	H3959_001_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.88	24	24	24				115.80	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
H3959	001	0	1	02	01	H3959_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.84	25	25	25				37.26	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	001	0	1	02	01	H3959_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1052.37	25						849.66	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
H3959	002	0	1	02	01	H3959_002_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	002	0	1	02	01	H3959_002_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	002	0	1	02	01	H3959_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											87.17	24	24	24				115.70	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
H3959	002	0	1	02	01	H3959_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											42.95	25	25	25				37.39	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	002	0	1	02	01	H3959_002_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											996.91	25						909.99	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
H3959	010	0	1	02	01	H3959_010_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	010	0	1	02	01	H3959_010_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3959	010	0	1	02	01	H3959_010_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.58	25	25	25				98.26	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	010	0	1	02	01	H3959_010_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.49	35	35	35				31.89	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
H3959	010	0	1	02	01	H3959_010_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1188.28	33						1543.83	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
H3959	011	0	1	02	01	H3959_011_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	011	0	1	02	01	H3959_011_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3959	011	0	1	02	01	H3959_011_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.62	25	25	25				99.10	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
H3959	011	0	1	02	01	H3959_011_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.03	35	35	35				33.46	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
H3959	011	0	1	02	01	H3959_011_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1040.72	33						1031.57	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
H3959	032	0	1	02	01	H3959_032_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	032	0	1	02	01	H3959_032_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	032	0	1	02	01	H3959_032_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.42	24	24	24				115.81	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
H3959	032	0	1	02	01	H3959_032_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.85	25	25	25				36.92	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	032	0	1	02	01	H3959_032_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1017.54	25						803.24	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
H3959	033	0	1	02	01	H3959_033_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	033	0	1	02	01	H3959_033_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	033	0	1	02	01	H3959_033_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.67	24	24	24				106.44	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
H3959	033	0	1	02	01	H3959_033_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.20	25	25	25				42.49	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	033	0	1	02	01	H3959_033_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											811.36	25						667.35	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
H3959	037	0	1	02	01	H3959_037_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	037	0	1	02	01	H3959_037_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	037	0	1	02	01	H3959_037_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.61	24	24	24				114.40	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
H3959	037	0	1	02	01	H3959_037_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.30	25	25	25				40.65	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	037	0	1	02	01	H3959_037_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											852.48	25						826.54	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
H3959	039	0	1	02	01	H3959_039_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	039	0	1	02	01	H3959_039_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	039	0	1	02	01	H3959_039_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.07	24	24	24				103.76	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
H3959	039	0	1	02	01	H3959_039_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.79	25	25	25				40.74	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	039	0	1	02	01	H3959_039_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											875.11	25						895.52	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
H3959	052	0	1	02	01	H3959_052_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	052	0	1	02	01	H3959_052_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	052	0	1	02	01	H3959_052_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.52	24	24	24				118.05	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
H3959	052	0	1	02	01	H3959_052_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.42	25	25	25				39.98	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
H3959	052	0	1	02	01	H3959_052_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											933.05	25						767.89	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
H3959	053	0	1	02	01	H3959_053_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	053	0	1	02	01	H3959_053_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	053	0	1	02	01	H3959_053_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											98.92	24	24	24				117.30	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
H3959	053	0	1	02	01	H3959_053_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.06	25	25	25				42.17	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	053	0	1	02	01	H3959_053_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											928.15	25						871.33	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
H3959	055	0	1	01	01	H3959_055_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	055	0	1	01	01	H3959_055_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3959	055	0	1	01	01	H3959_055_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.40	25	25	25				110.34	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	055	0	1	01	01	H3959_055_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.52	26	26	26				39.10	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	01	01	H3959_055_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											859.12	30						1104.29	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
H3959	076	0	1	01	01	H3959_076_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	076	0	1	01	01	H3959_076_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3959	076	0	1	01	01	H3959_076_0	2			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	076	0	1	01	01	H3959_076_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.76	50	50	50				62.82	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
H3959	076	0	1	01	01	H3959_076_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1070.45	29						1036.70	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
H3959	077	0	1	01	01	H3959_077_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H3959	077	0	1	01	01	H3959_077_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H3959	077	0	1	01	01	H3959_077_0	2			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	077	0	1	01	01	H3959_077_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.76	50	50	50				62.82	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
H3959	077	0	1	01	01	H3959_077_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1070.45	29						1036.58	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
H3962	001	0	1	01	01	H3962_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	001	0	1	01	01	H3962_001_0	4			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					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
H3962	001	0	1	01	01	H3962_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	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	200.00	300.00				100.00	200.00	300.00				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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											647.96	33						455.22	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
H3962	004	0	1	01	01	H3962_004_0	4			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				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	004	0	1	01	01	H3962_004_0	4			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					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
H3962	004	0	1	01	01	H3962_004_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.53	36	36	36				94.70	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
H3962	004	0	1	01	01	H3962_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											922.66	33						483.71	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
H3962	007	0	1	01	01	H3962_007_0	4			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				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	4			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					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
H3962	007	0	1	01	01	H3962_007_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											39.44	20	20	20				39.63	20	20	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	70.00	105.00	35.00		35.00
H3962	007	0	1	01	01	H3962_007_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											78.13	50	50	50				77.50	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
H3962	007	0	1	01	01	H3962_007_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											387.34	30						516.62	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
H3962	021	0	1	01	01	H3962_021_0	4			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				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	4			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					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
H3962	021	0	1	01	01	H3962_021_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.35	20	20	20				40.21	20	20	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	70.00	105.00	35.00		35.00
H3962	021	0	1	01	01	H3962_021_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.56	50	50	50				81.91	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
H3962	021	0	1	01	01	H3962_021_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											481.56	30						438.02	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
H3975	001	0	1	04	01	H3975_001_0	5			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																								
H3975	001	0	1	04	01	H3975_001_0	5			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																								
H3975	001	0	1	04	01	H3975_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.55	25	25	25				157.55	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
H3975	001	0	1	04	01	H3975_001_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											44.32	39	39	39				44.32	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
H3975	001	0	1	04	01	H3975_001_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, Select Care Drugs																								
H3975	001	0	1	04	01	H3975_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H3979	001	0	1	01	01	H3979_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H3979	001	0	1	01	01	H3979_001_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H3979	001	0	1	01	01	H3979_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					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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											69.70	50	50	50				65.97	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
H3979	001	0	1	01	01	H3979_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											585.08	33						518.41	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4003	009	0	1	01	01	H4003_009_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	009	0	1	01	01	H4003_009_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4003	009	0	1	01	01	H4003_009_0	9			Preferred Brand	4	10	1	2	3	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	009	0	1	01	01	H4003_009_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										10.00		20.00						20.00				10.00		10.00
H4003	009	0	1	01	01	H4003_009_0	9			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				745.83	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	009	0	1	01	01	H4003_009_0	9			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1713.07	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	009	0	1	01	01	H4003_009_0	9			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4003	019	0	1	02	01	H4003_019_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	019	0	1	02	01	H4003_019_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4003	019	0	1	02	01	H4003_019_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	019	0	1	02	01	H4003_019_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										5.00		10.00						10.00				5.00		5.00
H4003	019	0	1	02	01	H4003_019_0	9			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				531.79	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	019	0	1	02	01	H4003_019_0	9			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				2242.21	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	019	0	1	02	01	H4003_019_0	9			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4003	034	0	1	02	01	H4003_034_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	034	0	1	02	01	H4003_034_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4003	034	0	1	02	01	H4003_034_0	8			Preferred Brand	4	10	1	2	3	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	034	0	1	02	01	H4003_034_0	8			Non-Preferred Brand	4	10	1	2	4	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4003	034	0	1	02	01	H4003_034_0	8			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1455.84	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	034	0	1	02	01	H4003_034_0	8			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1613.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	034	0	1	02	01	H4003_034_0	8			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4003	055	0	1	02	01	H4003_055_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	055	0	1	02	01	H4003_055_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										4.00		8.00						8.00				4.00		4.00
H4003	055	0	1	02	01	H4003_055_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4003	055	0	1	02	01	H4003_055_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										15.00		30.00						30.00				15.00		15.00
H4003	055	0	1	02	01	H4003_055_0	8			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				734.35	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	055	0	1	02	01	H4003_055_0	8			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1716.38	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4003	055	0	1	02	01	H4003_055_0	8			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	056	0	1	02	01	H4004_056_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	056	0	1	02	01	H4004_056_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	056	0	1	02	01	H4004_056_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	056	0	1	02	01	H4004_056_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										10.00		20.00						20.00				10.00		10.00
H4004	056	0	1	02	01	H4004_056_0	8			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				475.26	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	056	0	1	02	01	H4004_056_0	8			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1210.72	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	056	0	1	02	01	H4004_056_0	8			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	063	0	1	02	01	H4004_063_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	063	0	1	02	01	H4004_063_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	063	0	1	02	01	H4004_063_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	063	0	1	02	01	H4004_063_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										10.00		20.00						20.00				10.00		10.00
H4004	063	0	1	02	01	H4004_063_0	8			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				3661.04	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	063	0	1	02	01	H4004_063_0	8			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1386.62	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	063	0	1	02	01	H4004_063_0	8			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	065	0	1	02	01	H4004_065_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	065	0	1	02	01	H4004_065_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	065	0	1	02	01	H4004_065_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	065	0	1	02	01	H4004_065_0	9			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										7.00		14.00						14.00				7.00		7.00
H4004	065	0	1	02	01	H4004_065_0	9			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				633.36	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	065	0	1	02	01	H4004_065_0	9			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1477.63	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	065	0	1	02	01	H4004_065_0	9			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	066	0	1	02	01	H4004_066_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	066	0	1	02	01	H4004_066_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										6.00		12.00						12.00				6.00		6.00
H4004	066	0	1	02	01	H4004_066_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	066	0	1	02	01	H4004_066_0	8			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										20.00		40.00						40.00				20.00		20.00
H4004	066	0	1	02	01	H4004_066_0	8			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				629.69	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	066	0	1	02	01	H4004_066_0	8			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1470.56	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	066	0	1	02	01	H4004_066_0	8			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	070	0	1	02	01	H4004_070_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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	070	0	1	02	01	H4004_070_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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	070	0	1	02	01	H4004_070_0	7			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	070	0	1	02	01	H4004_070_0	7			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										15.00		30.00						30.00				15.00		15.00
H4004	070	0	1	02	01	H4004_070_0	7			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				629.91	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	070	0	1	02	01	H4004_070_0	7			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1470.70	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	070	0	1	02	01	H4004_070_0	7			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4004	071	0	1	02	01	H4004_071_0	6			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	071	0	1	02	01	H4004_071_0	6			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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										2.00		4.00						4.00				2.00		2.00
H4004	071	0	1	02	01	H4004_071_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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																								
H4004	071	0	1	02	01	H4004_071_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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										15.00		30.00						30.00				15.00		15.00
H4004	071	0	1	02	01	H4004_071_0	6			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				631.40	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	071	0	1	02	01	H4004_071_0	6			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				1473.38	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H4004	071	0	1	02	01	H4004_071_0	6			Select Care Drugs	4	10	1	2	7	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, Preferred Specialty Tier, Specialty Tier, Select Care Drugs										0.00		0.00						0.00				0.00		0.00
H4005	004	0	1	04	01	H4005_004_0	9			Preferred Generic	4	01	3	2	1	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	9			Generic	4	01	3	2	2	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																								
H4005	004	0	1	04	01	H4005_004_0	9			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								45.00		90.00					0.00		0.00							0.00																45.00				0.00			1.50	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	9			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								75.00		150.00					10.00		20.00							20.00																75.00				10.00			2.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00		70.00	10.00		20.00			20.00				35.00		10.00
H4005	004	0	1	04	01	H4005_004_0	9			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	9			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
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	5.00		15.00																									6.00		18.00				5.00		5.00				5.00				5.00		0.17				0.20	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	012	0	1	01	01	H4007_012_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	31		31																								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		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	021	0	1	01	01	H4007_021_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	021	0	1	01	01	H4007_021_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	021	0	1	01	01	H4007_021_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									9.00		27.00				8.00		14.00				8.00				8.00		0.27				0.30	0.27	0.26	Preferred 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	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				94.00	28		28																								28		28				28		28			28			28								Preferred 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	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	021	0	1	01	01	H4007_021_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	024	0	1	01	01	H4007_024_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	024	0	1	01	01	H4007_024_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	024	0	1	01	01	H4007_024_0	4			Preferred Brand	4	11	1	2	3	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	024	0	1	01	01	H4007_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	33		33																								33		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		0.00	0.00		0.00
H4007	024	0	1	01	01	H4007_024_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	024	0	1	01	01	H4007_024_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	025	0	1	01	01	H4007_025_0	3			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	3			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	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	7.00		21.00																									11.00		33.00				7.00		14.00				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										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	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	30		30																								30		30				30		30			30			30								Preferred 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	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, Select Care Drugs										0.00						0.00			0.00			0.00		0.00
H4007	025	0	1	01	01	H4007_025_0	3			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	3			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	3			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	3			Preferred Brand	4	11	1	2	3	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	028	0	1	02	01	H4007_028_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				92.00	25		25																								25		25				25		25			25			25								Preferred 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	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, Select Care Drugs										0.00						0.00			0.00			0.00		0.00
H4007	028	0	1	02	01	H4007_028_0	3			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	3			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	3			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	3			Preferred Brand	4	11	1	2	3	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	029	0	1	01	01	H4007_029_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				92.00	30		30																								30		30				30		30			30			30								Preferred 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	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, Select Care Drugs										0.00						0.00			0.00			0.00		0.00
H4007	029	0	1	01	01	H4007_029_0	3			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	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																								
H4036	008	0	1	04	01	H4036_008_0	7			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																								
H4036	008	0	1	04	01	H4036_008_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.35	20	20	20				56.35	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	70.00				35.00		35.00
H4036	008	0	1	04	01	H4036_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											54.88	35	35	35				54.88	35	35	35				35	35	35															35			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
H4036	008	0	1	04	01	H4036_008_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																								
H4036	008	0	1	04	01	H4036_008_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																								
H4036	017	0	1	04	01	H4036_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								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																								
H4036	017	0	1	04	01	H4036_017_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	017	0	1	04	01	H4036_017_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.42	25	25	25				52.34	20	20	20				20	20	20															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	70.00				35.00		35.00
H4036	017	0	1	04	01	H4036_017_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											57.23	35	35	35				57.23	35	35	35				35	35	35															35			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
H4036	017	0	1	04	01	H4036_017_0	6			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	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																								
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			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																								
H4036	020	0	1	04	01	H4036_020_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.08	20	20	20				53.08	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	70.00				35.00		35.00
H4036	020	0	1	04	01	H4036_020_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.27	35	35	35				53.27	35	35	35				35	35	35															35			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
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	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																								
H4036	025	0	1	04	01	H4036_025_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	025	0	1	04	01	H4036_025_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	025	0	1	04	01	H4036_025_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.95	25	25	25				47.16	20	20	20				20	20	20															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	70.00				35.00		35.00
H4036	025	0	1	04	01	H4036_025_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											52.49	35	35	35				52.49	35	35	35				35	35	35															35			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
H4036	025	0	1	04	01	H4036_025_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	025	0	1	04	01	H4036_025_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																								
H4036	026	0	1	04	01	H4036_026_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																								
H4036	026	0	1	04	01	H4036_026_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																								
H4036	026	0	1	04	01	H4036_026_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.37	25	25	25				41.90	20	20	20				20	20	20															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	70.00				35.00		35.00
H4036	026	0	1	04	01	H4036_026_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											39.42	35	35	35				39.42	35	35	35				35	35	35															35			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
H4036	026	0	1	04	01	H4036_026_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	026	0	1	04	01	H4036_026_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																								
H4036	028	0	1	04	01	H4036_028_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																								
H4036	028	0	1	04	01	H4036_028_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																								
H4036	028	0	1	04	01	H4036_028_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.94	25	25	25				60.75	20	20	20				20	20	20															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	70.00				35.00		35.00
H4036	028	0	1	04	01	H4036_028_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											44.80	25	25	25				44.80	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		35.00
H4036	028	0	1	04	01	H4036_028_0	9			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																								
H4036	028	0	1	04	01	H4036_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	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																								
H4036	029	0	1	04	01	H4036_029_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																								
H4036	029	0	1	04	01	H4036_029_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.98	25	25	25				60.79	20	20	20				20	20	20															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	70.00				35.00		35.00
H4036	029	0	1	04	01	H4036_029_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											37.77	25	25	25				37.77	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		35.00
H4036	029	0	1	04	01	H4036_029_0	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, Select Care Drugs																								
H4036	029	0	1	04	01	H4036_029_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																								
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								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																								
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								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																								
H4036	030	0	1	04	01	H4036_030_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											43.63	20	20	20				43.63	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	70.00				35.00		35.00
H4036	030	0	1	04	01	H4036_030_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											47.60	35	35	35				47.60	35	35	35				35	35	35															35			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
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	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																								
H4036	033	0	1	04	01	H4036_033_0	6			Preferred Generic	4	11	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																								
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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4036	033	0	1	04	01	H4036_033_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											123.80	25	25	25				99.04	20	20	20				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	70.00				35.00		35.00
H4036	033	0	1	04	01	H4036_033_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											27.18	35	35	35				27.18	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		35.00
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												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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			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																								
H4036	034	0	1	04	01	H4036_034_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											41.01	20	20	20				41.01	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	70.00				35.00		35.00
H4036	034	0	1	04	01	H4036_034_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											45.30	35	35	35				45.30	35	35	35				35	35	35															35			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
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	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																								
H4036	035	0	1	04	01	H4036_035_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																								
H4036	035	0	1	04	01	H4036_035_0	6			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																								
H4036	035	0	1	04	01	H4036_035_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											37.50	20	20	20				37.50	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	70.00				35.00		35.00
H4036	035	0	1	04	01	H4036_035_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											36.23	35	35	35				36.23	35	35	35				35	35	35															35			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
H4036	035	0	1	04	01	H4036_035_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	035	0	1	04	01	H4036_035_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																								
H4036	036	0	1	04	01	H4036_036_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																								
H4036	036	0	1	04	01	H4036_036_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H4036	036	0	1	04	01	H4036_036_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.31	20	20	20				53.31	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	70.00				35.00		35.00
H4036	036	0	1	04	01	H4036_036_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											57.68	35	35	35				57.68	35	35	35				35	35	35															35			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
H4036	036	0	1	04	01	H4036_036_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																								
H4036	036	0	1	04	01	H4036_036_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																								
H4036	038	0	1	04	01	H4036_038_0	6			Preferred Generic	4	11	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																								
H4036	038	0	1	04	01	H4036_038_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																								
H4036	038	0	1	04	01	H4036_038_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											96.62	25	25	25				77.30	20	20	20				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	70.00				35.00		35.00
H4036	038	0	1	04	01	H4036_038_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											32.28	40	40	40				32.28	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
H4036	038	0	1	04	01	H4036_038_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																								
H4036	041	0	1	04	01	H4036_041_0	6			Preferred Generic	4	11	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																								
H4036	041	0	1	04	01	H4036_041_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H4036	041	0	1	04	01	H4036_041_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											99.85	20	20	20				99.85	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	70.00				35.00		35.00
H4036	041	0	1	04	01	H4036_041_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											27.26	35	35	35				27.26	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		35.00
H4036	041	0	1	04	01	H4036_041_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																								
H4036	042	0	1	04	01	H4036_042_0	5			Preferred Generic	4	11	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																								
H4036	042	0	1	04	01	H4036_042_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H4036	042	0	1	04	01	H4036_042_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											107.22	25	25	25				85.78	20	20	20				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	70.00				35.00		35.00
H4036	042	0	1	04	01	H4036_042_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											24.46	40	40	40				24.46	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
H4036	042	0	1	04	01	H4036_042_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																								
H4073	001	0	1	02	01	H4073_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																								
H4073	001	0	1	02	01	H4073_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H4073	001	0	1	02	01	H4073_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											164.00	25	25	25				164.00	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
H4073	001	0	1	02	01	H4073_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											59.66	42	42	42				59.66	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
H4073	001	0	1	02	01	H4073_001_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, Select Care Drugs																								
H4073	001	0	1	02	01	H4073_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																								
H4091	003	0	1	04	01	H4091_003_0	4			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	4			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	4			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	4			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	4			Specialty Tier	4	11	1	1	5	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				812.60	31	31	31																		31	31	31																31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H4140	001	0	1	01	01	H4140_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	0.00	0.00	0.00																			0.00	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	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, 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	8			Preferred Brand	4	11	1	2	3	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, 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	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	55.00	110.00	165.00																			55.00	110.00	165.00																55.00				55.00		1.83			1.83			1.77	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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				569.62	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	001	0	1	01	01	H4140_001_0	8			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																								
H4140	002	0	1	01	01	H4140_002_0	6		N	Preferred Generic	4	01	1	1	1	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, Supplemental Drugs																								
H4140	002	0	1	01	01	H4140_002_0	6		N	Generic	4	11	1	1	2	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, 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	6		N	Preferred Brand	4	11	1	1	3	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, 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	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					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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	002	0	1	01	01	H4140_002_0	6		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																								
H4140	004	0	1	01	01	H4140_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	0.00	0.00	0.00																			0.00	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	6			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, 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	6			Preferred Brand	4	11	1	2	3	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, Supplemental Drugs										20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H4140	004	0	1	01	01	H4140_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	55.00	110.00	165.00																			55.00	110.00	165.00																55.00				55.00		1.83			1.83			1.77	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	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				704.71	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	004	0	1	01	01	H4140_004_0	6			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																								
H4140	005	0	1	01	01	H4140_005_0	6			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, Supplemental Drugs																								
H4140	005	0	1	01	01	H4140_005_0	6			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, 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	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																			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
H4140	005	0	1	01	01	H4140_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																			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	005	0	1	01	01	H4140_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				670.79	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	005	0	1	01	01	H4140_005_0	6			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																								
H4140	009	0	1	01	01	H4140_009_0	6			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, Supplemental Drugs																								
H4140	009	0	1	01	01	H4140_009_0	6			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, 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	6			Preferred Brand	4	11	1	2	3	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, Supplemental Drugs										15.00	30.00	45.00				15.00	30.00	45.00				15.00		15.00
H4140	009	0	1	01	01	H4140_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	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, 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	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				627.99	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	009	0	1	01	01	H4140_009_0	6			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																								
H4140	010	0	1	01	01	H4140_010_0	6		N	Preferred Generic	4	01	1	1	1	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, Supplemental Drugs																								
H4140	010	0	1	01	01	H4140_010_0	6		N	Generic	4	11	1	1	2	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, 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	6		N	Preferred Brand	4	11	1	1	3	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, 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	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					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	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, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	010	0	1	01	01	H4140_010_0	6		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																								
H4140	012	0	1	01	01	H4140_012_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 Drug, Specialty Tier, Supplemental Drugs																								
H4140	012	0	1	01	01	H4140_012_0	5			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, 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	5			Preferred Brand	4	11	1	2	3	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, 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	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	55.00	110.00	165.00																			55.00	110.00	165.00																55.00				55.00		1.83			1.83			1.77	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	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				609.97	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	012	0	1	01	01	H4140_012_0	5			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																								
H4140	013	0	1	01	01	H4140_013_0	5		N	Preferred Generic	4	01	1	1	1	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, Supplemental Drugs																								
H4140	013	0	1	01	01	H4140_013_0	5		N	Generic	4	11	1	1	2	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, 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	5		N	Preferred Brand	4	11	1	1	3	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, 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	5		N	Non-Preferred Drug	4	11	1	1	4	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, 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	5		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
H4140	013	0	1	01	01	H4140_013_0	5		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																								
H4140	014	0	1	01	01	H4140_014_0	6			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, Supplemental Drugs																								
H4140	014	0	1	01	01	H4140_014_0	6			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, Supplemental Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	014	0	1	01	01	H4140_014_0	6			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, Supplemental Drugs										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	014	0	1	01	01	H4140_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		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	014	0	1	01	01	H4140_014_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				609.80	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H4140	014	0	1	01	01	H4140_014_0	6			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																								
H4141	015	0	1	01	01	H4141_015_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
H4141	015	0	1	01	01	H4141_015_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
H4141	015	0	1	01	01	H4141_015_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		95.00	35.00		35.00
H4141	015	0	1	01	01	H4141_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		105.00	35.00		35.00
H4141	015	0	1	01	01	H4141_015_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
H4141	017	3	1	01	01	H4141_017_3	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
H4141	017	3	1	01	01	H4141_017_3	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
H4141	017	3	1	01	01	H4141_017_3	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		95.00	35.00		35.00
H4141	017	3	1	01	01	H4141_017_3	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		35.00
H4141	017	3	1	01	01	H4141_017_3	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
H4141	017	5	1	01	01	H4141_017_5	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
H4141	017	5	1	01	01	H4141_017_5	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
H4141	017	5	1	01	01	H4141_017_5	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		95.00	35.00		35.00
H4141	017	5	1	01	01	H4141_017_5	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		35.00
H4141	017	5	1	01	01	H4141_017_5	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
H4141	022	0	1	01	01	H4141_022_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
H4141	022	0	1	01	01	H4141_022_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
H4141	022	0	1	01	01	H4141_022_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		95.00	35.00		35.00
H4141	022	0	1	01	01	H4141_022_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H4141	022	0	1	01	01	H4141_022_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
H4141	023	0	1	01	01	H4141_023_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
H4141	023	0	1	01	01	H4141_023_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
H4141	023	0	1	01	01	H4141_023_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		95.00	35.00		35.00
H4141	023	0	1	01	01	H4141_023_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H4141	023	0	1	01	01	H4141_023_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
H4152	005	0	1	01	01	H4152_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01		101	1	30	60	100				1	2					60	100	30		31	3.00	6.00	9.00																										22.00	33.00					0.00	0.00				3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										3.00	6.00	9.00					22.00	33.00		0.00	0.00	3.00		3.00
H4152	005	0	1	01	01	H4152_005_0	6			Generic	4	01	1	2	2	1	111		01		101	1	30	60	100				1	2					60	100	30		31	6.00	12.00	18.00																										28.00	42.00					0.00	0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										6.00	12.00	18.00					28.00	42.00		0.00	0.00	6.00		6.00
H4152	005	0	1	01	01	H4152_005_0	6			Preferred Brand	4	11	1	2	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31	47.00	94.00	141.00																										94.00	141.00					94.00	117.50				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	105.00		70.00	105.00	35.00		35.00
H4152	005	0	1	01	01	H4152_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31	100.00	200.00	300.00																										200.00	300.00					200.00	250.00				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	105.00		70.00	105.00	35.00		35.00
H4152	005	0	1	01	01	H4152_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																								
H4152	007	0	1	02	01	H4152_007_0	6			Preferred Generic	4	11	1	2	1	1	111		01		101	1	30	60	100				1	2					60	100	30		31	3.00	6.00	9.00																										22.00	33.00					0.00	0.00				3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										3.00	6.00	9.00					22.00	33.00		0.00	0.00	3.00		3.00
H4152	007	0	1	02	01	H4152_007_0	6			Generic	4	01	1	2	2	1	111		01		101	1	30	60	100				1	2					60	100	30		31	6.00	12.00	18.00																										28.00	42.00					0.00	0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										6.00	12.00	18.00					28.00	42.00		0.00	0.00	6.00		6.00
H4152	007	0	1	02	01	H4152_007_0	6			Preferred Brand	4	11	1	2	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31	47.00	94.00	141.00																										94.00	141.00					94.00	117.50				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	105.00		70.00	105.00	35.00		35.00
H4152	007	0	1	02	01	H4152_007_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31	100.00	200.00	300.00																										200.00	300.00					200.00	250.00				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	105.00		70.00	105.00	35.00		35.00
H4152	007	0	1	02	01	H4152_007_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																								
H4152	013	0	1	02	01	H4152_013_0	6			Preferred Generic	4	11	1	2	1	1	111		01		101	1	30	60	100				1	2					60	100	30		31	0.00	0.00	0.00																										16.00	24.00					0.00	0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00					16.00	24.00		0.00	0.00	0.00		0.00
H4152	013	0	1	02	01	H4152_013_0	6			Generic	4	01	1	2	2	1	111		01		101	1	30	60	100				1	2					60	100	30		31	3.00	6.00	9.00																										32.00	48.00					0.00	0.00				3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										3.00	6.00	9.00					32.00	48.00		0.00	0.00	3.00		3.00
H4152	013	0	1	02	01	H4152_013_0	6			Preferred Brand	4	11	1	2	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31	47.00	94.00	141.00																										94.00	141.00					94.00	117.50				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	105.00		70.00	105.00	35.00		35.00
H4152	013	0	1	02	01	H4152_013_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31				44.77	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					70.00	105.00		70.00	105.00	35.00		35.00
H4152	013	0	1	02	01	H4152_013_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																								
H4152	018	0	1	02	01	H4152_018_0	6			Preferred Generic	4	11	1	2	1	1	111		01		101	1	30	60	100				1	2					60	100	30		31	0.00	0.00	0.00																										16.00	24.00					0.00	0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00					16.00	24.00		0.00	0.00	0.00		0.00
H4152	018	0	1	02	01	H4152_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																										24.00	36.00					0.00	0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00					24.00	36.00		0.00	0.00	0.00		0.00
H4152	018	0	1	02	01	H4152_018_0	6			Preferred Brand	4	11	1	2	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31	47.00	94.00	141.00																										94.00	141.00					94.00	117.50				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	105.00		70.00	105.00	35.00		35.00
H4152	018	0	1	02	01	H4152_018_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31	100.00	200.00	300.00																										200.00	300.00					200.00	250.00				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	105.00		70.00	105.00	35.00		35.00
H4152	018	0	1	02	01	H4152_018_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																								
H4152	020	0	1	02	01	H4152_020_0	6			Preferred Generic	4	11	1	2	1	1	111		01		101	1	30	60	100				1	2					60	100	30		31	0.00	0.00	0.00																										16.00	24.00					0.00	0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00					16.00	24.00		0.00	0.00	0.00		0.00
H4152	020	0	1	02	01	H4152_020_0	6			Generic	4	01	1	2	2	1	111		01		101	1	30	60	100				1	2					60	100	30		31	5.00	10.00	15.00																										32.00	48.00					0.00	0.00				5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										5.00	10.00	15.00					32.00	48.00		0.00	0.00	5.00		5.00
H4152	020	0	1	02	01	H4152_020_0	6			Preferred Brand	4	11	1	2	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31	47.00	94.00	141.00																										94.00	141.00					94.00	117.50				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	105.00		70.00	105.00	35.00		35.00
H4152	020	0	1	02	01	H4152_020_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31				56.18	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					70.00	105.00		70.00	105.00	35.00		35.00
H4152	020	0	1	02	01	H4152_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																								
H4161	002	0	1	02	01	H4161_002_0	7			Preferred Generic	4	11	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	02	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	02	01	H4161_002_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.72	20	20	20				56.79	15	15	15				15	15	15															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	70.00				35.00		35.00
H4161	002	0	1	02	01	H4161_002_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.44	35	35	35				75.44	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		35.00
H4161	002	0	1	02	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	02	01	H4161_003_0	7			Preferred Generic	4	11	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	02	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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	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	02	01	H4161_003_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											80.82	20	20	20				60.62	15	15	15				15	15	15															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	70.00				35.00		35.00
H4161	003	0	1	02	01	H4161_003_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											61.21	25	25	25				61.21	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		35.00
H4161	003	0	1	02	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	02	01	H4161_004_0	7			Preferred Generic	4	11	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	02	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								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																								
H4161	004	0	1	02	01	H4161_004_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											67.33	20	20	20				67.33	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
H4161	004	0	1	02	01	H4161_004_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											54.67	35	35	35				54.67	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		35.00
H4161	004	0	1	02	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	02	01	H4161_005_0	7			Preferred Generic	4	11	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	02	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	02	01	H4161_005_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											97.22	25	25	25				77.78	20	20	20				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	70.00				35.00		35.00
H4161	005	0	1	02	01	H4161_005_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											44.40	25	25	25				44.40	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		35.00
H4161	005	0	1	02	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	02	01	H4161_006_0	7			Preferred Generic	4	11	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	02	01	H4161_006_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H4161	006	0	1	02	01	H4161_006_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											63.90	20	20	20				63.90	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
H4161	006	0	1	02	01	H4161_006_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											54.19	35	35	35				54.19	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		35.00
H4161	006	0	1	02	01	H4161_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																								
H4161	007	0	1	02	01	H4161_007_0	7			Preferred Generic	4	11	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	02	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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	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	02	01	H4161_007_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.47	25	25	25				67.58	20	20	20				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		35.00
H4161	007	0	1	02	01	H4161_007_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.81	35	35	35				56.81	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		35.00
H4161	007	0	1	02	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	02	01	H4161_009_0	7			Preferred Generic	4	11	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	02	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	02	01	H4161_009_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											74.90	20	20	20				55.57	15	15	15				15	15	15															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	70.00				35.00		35.00
H4161	009	0	1	02	01	H4161_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											76.58	35	35	35				76.58	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		35.00
H4161	009	0	1	02	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	02	01	H4161_010_0	7			Preferred Generic	4	11	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	02	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	02	01	H4161_010_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											92.87	25	25	25				74.30	20	20	20				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	70.00				35.00		35.00
H4161	010	0	1	02	01	H4161_010_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											40.72	25	25	25				40.72	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		35.00
H4161	010	0	1	02	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	02	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	02	01	H4161_011_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	011	0	1	02	01	H4161_011_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											73.54	20	20	20				55.15	15	15	15				15	15	15															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	70.00				35.00		35.00
H4161	011	0	1	02	01	H4161_011_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											77.44	25	25	25				77.44	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		35.00
H4161	011	0	1	02	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	02	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	012	0	1	02	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	02	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	02	01	H4161_012_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.91	20	20	20				56.93	15	15	15				15	15	15															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	70.00				35.00		35.00
H4161	012	0	1	02	01	H4161_012_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											81.35	25	25	25				81.35	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		35.00
H4161	012	0	1	02	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	02	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	013	0	1	02	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	02	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	02	01	H4161_013_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.38	20	20	20				54.28	15	15	15				15	15	15															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	70.00				35.00		35.00
H4161	013	0	1	02	01	H4161_013_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											76.62	25	25	25				76.62	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		35.00
H4161	013	0	1	02	01	H4161_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																								
H4161	013	0	1	02	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	014	0	1	02	01	H4161_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4161	014	0	1	02	01	H4161_014_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																								
H4161	014	0	1	02	01	H4161_014_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											120.77	25	25	25				96.62	20	20	20				20	20	20															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	70.00				35.00		35.00
H4161	014	0	1	02	01	H4161_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											80.79	25	25	25				80.79	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		35.00
H4161	014	0	1	02	01	H4161_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, Select Care Drugs																								
H4161	014	0	1	02	01	H4161_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			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	015	0	1	02	01	H4161_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								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																								
H4161	015	0	1	02	01	H4161_015_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																								
H4161	015	0	1	02	01	H4161_015_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											118.10	25	25	25				94.48	20	20	20				20	20	20															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	70.00				35.00		35.00
H4161	015	0	1	02	01	H4161_015_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											78.53	25	25	25				78.53	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		35.00
H4161	015	0	1	02	01	H4161_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																								
H4161	015	0	1	02	01	H4161_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
H4161	016	0	1	02	01	H4161_016_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																								
H4161	016	0	1	02	01	H4161_016_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																								
H4161	016	0	1	02	01	H4161_016_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											91.55	25	25	25				73.24	20	20	20				20	20	20															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	70.00				35.00		35.00
H4161	016	0	1	02	01	H4161_016_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											73.17	25	25	25				73.17	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		35.00
H4161	016	0	1	02	01	H4161_016_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																								
H4161	016	0	1	02	01	H4161_016_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
H4161	017	0	1	02	01	H4161_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								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																								
H4161	017	0	1	02	01	H4161_017_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																								
H4161	017	0	1	02	01	H4161_017_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											88.79	25	25	25				71.03	20	20	20				20	20	20															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	70.00				35.00		35.00
H4161	017	0	1	02	01	H4161_017_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											70.43	25	25	25				70.43	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		35.00
H4161	017	0	1	02	01	H4161_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																								
H4161	017	0	1	02	01	H4161_017_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
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	10.00		25.00																			10.00		0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	15.00		37.50																			15.00		0.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4213	017	1	1	09	04	H4213_017_1	3			Preferred Brand	3	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				45.19	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
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				69.82	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		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				110.28	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
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	10.00		25.00																			10.00		0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	15.00		37.50																			15.00		0.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4213	017	5	1	09	04	H4213_017_5	3			Preferred Brand	3	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				45.19	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
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				69.82	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		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				110.28	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
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	10.00		25.00																			10.00		0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	15.00		37.50																			15.00		0.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4213	017	6	1	09	04	H4213_017_6	3			Preferred Brand	3	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				45.19	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
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				69.82	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		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				110.28	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H4286	001	0	1	01	01	H4286_001_0	7			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs										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	7			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 Drug, Specialty Tier, Supplemental Drugs										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	7			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00									35.00		35.00
H4286	001	0	1	01	01	H4286_001_0	7			Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											495.58	33						407.96	33																							33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H4286	001	0	1	01	01	H4286_001_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H4286	002	0	1	01	01	H4286_002_0	10		N	Generic	4	01	1	1	1	1		111	01			1				30	60	90	2	2							30		31											2.60	20	20	20				2.34	20	20	20																					20			20								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
H4286	002	0	1	01	01	H4286_002_0	10		N	Preferred Brand	4	11	1	1	2	1		111	01			1				30	60	90	2	2							30		31											92.63	20	20	20				89.52	20	20	20																					20			20								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
H4286	002	0	1	01	01	H4286_002_0	10		N	Non-Preferred Drug	4	11	1	1	3	1		010	01			1				30											30		31											80.16	26						63.47	26																							26			26								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00									35.00		35.00
H4286	002	0	1	01	01	H4286_002_0	10		N	Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											414.43	25						524.66	25																							25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H4286	002	0	1	01	01	H4286_002_0	10		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 Drug, Specialty Tier, Supplemental Drugs																								
H4286	003	0	1	01	01	H4286_003_0	7			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs										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	7			Preferred Brand	4	11	1	2	2	1		111	01			1				30	60	90	2	2							30		31								40.00	80.00	120.00					30.00	60.00	90.00																							40.00				40.00			1.33	1.00				1.29	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00	70.00	105.00	30.00	60.00	90.00							35.00		35.00
H4286	003	0	1	01	01	H4286_003_0	7			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00									35.00		35.00
H4286	003	0	1	01	01	H4286_003_0	7			Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											695.92	33						440.90	33																							33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H4286	003	0	1	01	01	H4286_003_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H4286	004	0	1	01	01	H4286_004_0	10			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs										5.00	10.00	15.00	0.00	0.00	0.00							5.00		5.00
H4286	004	0	1	01	01	H4286_004_0	10			Preferred Brand	4	11	1	2	2	1		111	01			1				30	60	90	2	2							30		31								47.00	94.00	141.00					40.00	80.00	120.00																							47.00				47.00			1.57	1.33				1.52	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
H4286	004	0	1	01	01	H4286_004_0	10			Non-Preferred Drug	4	11	1	2	3	1		010	01			1				30											30		31								70.00							60.00																									70.00				70.00			2.33	2.00				2.26	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00									35.00		35.00
H4286	004	0	1	01	01	H4286_004_0	10			Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											491.64	33						408.86	33																							33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H4286	004	0	1	01	01	H4286_004_0	10			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 Drug, Specialty Tier, Supplemental Drugs																								
H4286	005	0	1	01	01	H4286_005_0	9		N	Generic	4	11	1	1	1	1		111	01			1				30	60	90	2	2							30		31											2.60	20	20	20				2.34	20	20	20																					20			20								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
H4286	005	0	1	01	01	H4286_005_0	9		N	Preferred Brand	4	11	1	1	2	1		111	01			1				30	60	90	2	2							30		31											92.63	20	20	20				89.52	20	20	20																					20			20								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
H4286	005	0	1	01	01	H4286_005_0	9		N	Non-Preferred Drug	4	11	1	1	3	1		010	01			1				30											30		31											80.16	26						63.47	26																							26			26								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00									35.00		35.00
H4286	005	0	1	01	01	H4286_005_0	9		N	Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											414.43	25						524.66	25																							25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H4286	005	0	1	01	01	H4286_005_0	9		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 Drug, Specialty Tier, Supplemental Drugs																								
H4346	001	0	1	02	01	H4346_001_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																								
H4346	001	0	1	02	01	H4346_001_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																								
H4346	001	0	1	02	01	H4346_001_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											91.26	25	25	25				73.01	20	20	20				20	20	20															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	70.00				35.00		35.00
H4346	001	0	1	02	01	H4346_001_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											59.24	25	25	25				59.24	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		35.00
H4346	001	0	1	02	01	H4346_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 Drug, Specialty Tier, Select Care Drugs																								
H4346	001	0	1	02	01	H4346_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	02	01	H4346_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								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	02	01	H4346_005_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																								
H4346	005	0	1	02	01	H4346_005_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											81.56	25	25	25				65.25	20	20	20				20	20	20															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	70.00				35.00		35.00
H4346	005	0	1	02	01	H4346_005_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											56.72	25	25	25				56.72	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		35.00
H4346	005	0	1	02	01	H4346_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																								
H4346	005	0	1	02	01	H4346_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	02	01	H4346_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																								
H4346	006	0	1	02	01	H4346_006_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																								
H4346	006	0	1	02	01	H4346_006_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											110.13	25	25	25				88.10	20	20	20				20	20	20															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	70.00				35.00		35.00
H4346	006	0	1	02	01	H4346_006_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											68.59	25	25	25				68.59	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		35.00
H4346	006	0	1	02	01	H4346_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																								
H4346	006	0	1	02	01	H4346_006_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
H4346	010	0	1	01	01	H4346_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4346	010	0	1	01	01	H4346_010_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																								
H4346	010	0	1	01	01	H4346_010_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				110.79	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	70.00				35.00		35.00
H4346	010	0	1	01	01	H4346_010_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				61.30	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
H4346	010	0	1	01	01	H4346_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																								
H4346	010	0	1	01	01	H4346_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
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								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	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								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																								
H4346	012	0	1	01	01	H4346_012_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.28	20	20	20				50.28	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		35.00
H4346	012	0	1	01	01	H4346_012_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											59.90	35	35	35				59.90	35	35	35				35	35	35															35			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
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	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																								
H4346	017	0	1	02	01	H4346_017_0	7			Preferred Generic	4	11	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	02	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								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																								
H4346	017	0	1	02	01	H4346_017_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											70.89	20	20	20				70.89	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	70.00				35.00		35.00
H4346	017	0	1	02	01	H4346_017_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											61.47	35	35	35				61.47	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		35.00
H4346	017	0	1	02	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	02	01	H4346_019_0	6			Preferred Generic	4	11	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	02	01	H4346_019_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																								
H4346	019	0	1	02	01	H4346_019_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											68.73	20	20	20				68.73	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
H4346	019	0	1	02	01	H4346_019_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											57.07	35	35	35				57.07	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		35.00
H4346	019	0	1	02	01	H4346_019_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																								
H4346	026	0	1	01	01	H4346_026_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	1.00	2.00	3.00																			1.00	3.00	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																								
H4346	026	0	1	01	01	H4346_026_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	6.00	12.00	18.00																			6.00	18.00	18.00																6.00				6.00		0.20			0.20			0.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4346	026	0	1	01	01	H4346_026_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				76.72	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		35.00
H4346	026	0	1	01	01	H4346_026_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				69.85	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
H4346	026	0	1	01	01	H4346_026_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, Select Care Drugs																								
H4346	026	0	1	01	01	H4346_026_0	6		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	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
H4346	029	0	1	02	01	H4346_029_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																								
H4346	029	0	1	02	01	H4346_029_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					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	02	01	H4346_029_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											59.28	25	25	25				47.42	20	20	20				20	20	20															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		35.00
H4346	029	0	1	02	01	H4346_029_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											72.46	25	25	25				72.46	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	70.00	105.00				35.00		35.00
H4346	029	0	1	02	01	H4346_029_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																								
H4346	029	0	1	02	01	H4346_029_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4407	027	0	1	01	01	H4407_027_0	4			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
H4407	027	0	1	01	01	H4407_027_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	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
H4407	027	0	1	01	01	H4407_027_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H4407	027	0	1	01	01	H4407_027_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											854.81	33						665.92	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
H4407	028	0	1	01	01	H4407_028_0	4			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
H4407	028	0	1	01	01	H4407_028_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	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
H4407	028	0	1	01	01	H4407_028_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H4407	028	0	1	01	01	H4407_028_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											801.82	33						615.83	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
H4407	030	1	1	01	01	H4407_030_1	4			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
H4407	030	1	1	01	01	H4407_030_1	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	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	4			Preferred Brand	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	030	1	1	01	01	H4407_030_1	4			Non-Preferred Drug	4	11	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
H4407	030	1	1	01	01	H4407_030_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											743.41	33						621.75	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
H4407	030	2	1	01	01	H4407_030_2	4			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
H4407	030	2	1	01	01	H4407_030_2	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	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	4			Preferred Brand	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	030	2	1	01	01	H4407_030_2	4			Non-Preferred Drug	4	11	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
H4407	030	2	1	01	01	H4407_030_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											743.41	33						621.75	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
H4407	030	3	1	01	01	H4407_030_3	4			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
H4407	030	3	1	01	01	H4407_030_3	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	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	4			Preferred Brand	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	030	3	1	01	01	H4407_030_3	4			Non-Preferred Drug	4	11	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
H4407	030	3	1	01	01	H4407_030_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											743.41	33						621.75	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
H4461	025	0	1	01	01	H4461_025_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
H4461	025	0	1	01	01	H4461_025_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
H4461	025	0	1	01	01	H4461_025_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		95.00	35.00		35.00
H4461	025	0	1	01	01	H4461_025_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H4461	025	0	1	01	01	H4461_025_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
H4461	035	0	1	01	01	H4461_035_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
H4461	035	0	1	01	01	H4461_035_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
H4461	035	0	1	01	01	H4461_035_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		95.00	35.00		35.00
H4461	035	0	1	01	01	H4461_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H4461	035	0	1	01	01	H4461_035_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
H4461	039	0	1	01	01	H4461_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
H4461	039	0	1	01	01	H4461_039_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	7.00		21.00																									20.00		60.00				7.00		0.00				7.00				7.00		0.23				0.67	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00		21.00				20.00		60.00	7.00		0.00	7.00		7.00
H4461	039	0	1	01	01	H4461_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		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		70.00	35.00		35.00
H4461	039	0	1	01	01	H4461_039_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	42		42																								42		42				42		42			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
H4461	039	0	1	01	01	H4461_039_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
H4461	040	0	1	01	01	H4461_040_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
H4461	040	0	1	01	01	H4461_040_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
H4461	040	0	1	01	01	H4461_040_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		95.00	35.00		35.00
H4461	040	0	1	01	01	H4461_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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
H4461	040	0	1	01	01	H4461_040_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
H4461	041	0	1	01	01	H4461_041_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
H4461	041	0	1	01	01	H4461_041_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
H4461	041	0	1	01	01	H4461_041_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		95.00	35.00		35.00
H4461	041	0	1	01	01	H4461_041_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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		35.00
H4461	041	0	1	01	01	H4461_041_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
H4461	042	0	1	01	01	H4461_042_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4461	042	0	1	01	01	H4461_042_0	4			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
H4461	042	0	1	01	01	H4461_042_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4461	042	0	1	01	01	H4461_042_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4461	042	0	1	01	01	H4461_042_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H4461	042	0	1	01	01	H4461_042_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				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
H4461	043	1	1	01	01	H4461_043_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
H4461	043	1	1	01	01	H4461_043_1	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
H4461	043	1	1	01	01	H4461_043_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		95.00	35.00		35.00
H4461	043	1	1	01	01	H4461_043_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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		35.00
H4461	043	1	1	01	01	H4461_043_1	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
H4461	043	2	1	01	01	H4461_043_2	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
H4461	043	2	1	01	01	H4461_043_2	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
H4461	043	2	1	01	01	H4461_043_2	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		95.00	35.00		35.00
H4461	043	2	1	01	01	H4461_043_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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		35.00
H4461	043	2	1	01	01	H4461_043_2	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
H4471	003	0	1	01	01	H4471_003_0	7		N	Preferred Generic	4	11	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4471	003	0	1	01	01	H4471_003_0	7		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	3.00	6.00	9.00																			3.00	9.00	9.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4471	003	0	1	01	01	H4471_003_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				97.02	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	003	0	1	01	01	H4471_003_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				58.46	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	003	0	1	01	01	H4471_003_0	7		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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.91	50	50	50				51.51	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
H4497	001	1	1	04	01	H4497_001_1	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																								
H4497	001	2	1	04	01	H4497_001_2	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.91	50	50	50				51.51	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
H4497	001	2	1	04	01	H4497_001_2	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																								
H4497	001	3	1	04	01	H4497_001_3	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.91	50	50	50				51.51	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
H4497	001	3	1	04	01	H4497_001_3	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																								
H4497	002	1	1	04	01	H4497_002_1	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.78	50	50	50				48.32	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
H4497	002	1	1	04	01	H4497_002_1	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.78	50	50	50				48.32	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
H4497	002	2	1	04	01	H4497_002_2	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.78	50	50	50				48.32	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
H4497	002	3	1	04	01	H4497_002_3	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.40	50	50	50				43.77	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
H4497	003	1	1	04	01	H4497_003_1	5			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	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	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	6			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	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	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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.40	50	50	50				43.77	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
H4497	003	2	1	04	01	H4497_003_2	6			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.40	50	50	50				43.77	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
H4497	003	3	1	04	01	H4497_003_3	5			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	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	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	5			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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.73	50	50	50				48.74	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
H4497	005	3	1	04	01	H4497_005_3	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																								
H4497	005	3	1	04	01	H4497_005_3	5			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	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	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	5			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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.73	50	50	50				48.74	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
H4497	005	4	1	04	01	H4497_005_4	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																								
H4497	005	4	1	04	01	H4497_005_4	5			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																								
H4506	003	0	1	02	01	H4506_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			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	02	01	H4506_003_0	5			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	02	01	H4506_003_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											152.89	25	25	25				152.89	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
H4506	003	0	1	02	01	H4506_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											65.03	39	39	39				65.03	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
H4506	003	0	1	02	01	H4506_003_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, Select Care Drugs																								
H4506	003	0	1	02	01	H4506_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																								
H4506	029	0	1	02	01	H4506_029_0	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.14	25	25	25				157.14	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
H4506	029	0	1	02	01	H4506_029_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											45.87	36	36	36				45.87	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
H4506	029	0	1	02	01	H4506_029_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, Select Care Drugs																								
H4506	029	0	1	02	01	H4506_029_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																								
H4506	030	0	1	02	01	H4506_030_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																								
H4506	030	0	1	02	01	H4506_030_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	030	0	1	02	01	H4506_030_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.06	25	25	25				154.06	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
H4506	030	0	1	02	01	H4506_030_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											45.42	37	37	37				45.42	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
H4506	030	0	1	02	01	H4506_030_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, Select Care Drugs																								
H4506	030	0	1	02	01	H4506_030_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																								
H4513	026	0	1	01	01	H4513_026_0	4			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
H4513	026	0	1	01	01	H4513_026_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	026	0	1	01	01	H4513_026_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											731.47	33						683.63	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	027	0	1	01	01	H4513_027_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	19.00	38.00	57.00																			19.00	38.00	57.00																19.00				19.00		0.63			0.63			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00
H4513	027	0	1	01	01	H4513_027_0	5		N	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																			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
H4513	027	0	1	01	01	H4513_027_0	5		N	Preferred Brand	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				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
H4513	027	0	1	01	01	H4513_027_0	5		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	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
H4513	027	0	1	01	01	H4513_027_0	5		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										35.00						35.00						35.00		35.00
H4513	030	0	1	01	01	H4513_030_0	4			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
H4513	030	0	1	01	01	H4513_030_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	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	030	0	1	01	01	H4513_030_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	030	0	1	01	01	H4513_030_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											769.20	33						552.72	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
H4513	036	0	1	02	01	H4513_036_0	4			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
H4513	036	0	1	02	01	H4513_036_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	036	0	1	02	01	H4513_036_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											854.44	33						550.30	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
H4513	037	0	1	01	01	H4513_037_0	4			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
H4513	037	0	1	01	01	H4513_037_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	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	037	0	1	01	01	H4513_037_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	037	0	1	01	01	H4513_037_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											929.38	33						705.05	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
H4513	038	0	1	01	01	H4513_038_0	4			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
H4513	038	0	1	01	01	H4513_038_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	038	0	1	01	01	H4513_038_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											823.73	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
H4513	046	1	1	01	01	H4513_046_1	4			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
H4513	046	1	1	01	01	H4513_046_1	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	046	1	1	01	01	H4513_046_1	4			Preferred Brand	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	046	1	1	01	01	H4513_046_1	4			Non-Preferred Drug	4	11	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	046	1	1	01	01	H4513_046_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											821.70	33						830.35	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
H4513	046	2	1	01	01	H4513_046_2	4			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
H4513	046	2	1	01	01	H4513_046_2	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	046	2	1	01	01	H4513_046_2	4			Preferred Brand	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	046	2	1	01	01	H4513_046_2	4			Non-Preferred Drug	4	11	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	046	2	1	01	01	H4513_046_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											821.70	33						830.35	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
H4513	049	1	1	01	01	H4513_049_1	4			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
H4513	049	1	1	01	01	H4513_049_1	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	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	049	1	1	01	01	H4513_049_1	4			Preferred Brand	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	049	1	1	01	01	H4513_049_1	4			Non-Preferred Drug	4	11	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	049	1	1	01	01	H4513_049_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											847.10	33						672.77	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
H4513	049	2	1	01	01	H4513_049_2	4			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
H4513	049	2	1	01	01	H4513_049_2	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	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	049	2	1	01	01	H4513_049_2	4			Preferred Brand	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	049	2	1	01	01	H4513_049_2	4			Non-Preferred Drug	4	11	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	049	2	1	01	01	H4513_049_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											847.10	33						672.77	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
H4513	049	3	1	01	01	H4513_049_3	4			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
H4513	049	3	1	01	01	H4513_049_3	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	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	049	3	1	01	01	H4513_049_3	4			Preferred Brand	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	049	3	1	01	01	H4513_049_3	4			Non-Preferred Drug	4	11	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	049	3	1	01	01	H4513_049_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											847.10	33						672.77	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
H4513	049	4	1	01	01	H4513_049_4	4			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
H4513	049	4	1	01	01	H4513_049_4	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	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	049	4	1	01	01	H4513_049_4	4			Preferred Brand	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	049	4	1	01	01	H4513_049_4	4			Non-Preferred Drug	4	11	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	049	4	1	01	01	H4513_049_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											847.10	33						672.77	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
H4513	049	5	1	01	01	H4513_049_5	4			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
H4513	049	5	1	01	01	H4513_049_5	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	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	049	5	1	01	01	H4513_049_5	4			Preferred Brand	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	049	5	1	01	01	H4513_049_5	4			Non-Preferred Drug	4	11	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	049	5	1	01	01	H4513_049_5	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											847.10	33						672.77	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
H4513	050	0	1	01	01	H4513_050_0	4			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
H4513	050	0	1	01	01	H4513_050_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	050	0	1	01	01	H4513_050_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											821.21	33						656.00	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
H4513	052	0	1	01	01	H4513_052_0	4			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
H4513	052	0	1	01	01	H4513_052_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	052	0	1	01	01	H4513_052_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											871.77	33						659.07	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
H4513	059	0	1	01	01	H4513_059_0	4			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
H4513	059	0	1	01	01	H4513_059_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	059	0	1	01	01	H4513_059_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											956.81	33						774.83	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
H4513	060	1	1	01	01	H4513_060_1	5		N	Preferred Generic	4	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																			19.00	38.00	57.00																19.00				19.00		0.63			0.63			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00
H4513	060	1	1	01	01	H4513_060_1	5		N	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																			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
H4513	060	1	1	01	01	H4513_060_1	5		N	Preferred Brand	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				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
H4513	060	1	1	01	01	H4513_060_1	5		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	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
H4513	060	1	1	01	01	H4513_060_1	5		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										35.00						35.00						35.00		35.00
H4513	060	2	1	01	01	H4513_060_2	5		N	Preferred Generic	4	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																			19.00	38.00	57.00																19.00				19.00		0.63			0.63			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00
H4513	060	2	1	01	01	H4513_060_2	5		N	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																			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
H4513	060	2	1	01	01	H4513_060_2	5		N	Preferred Brand	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				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
H4513	060	2	1	01	01	H4513_060_2	5		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	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
H4513	060	2	1	01	01	H4513_060_2	5		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										35.00						35.00						35.00		35.00
H4513	060	3	1	01	01	H4513_060_3	5		N	Preferred Generic	4	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																			19.00	38.00	57.00																19.00				19.00		0.63			0.63			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00
H4513	060	3	1	01	01	H4513_060_3	5		N	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																			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
H4513	060	3	1	01	01	H4513_060_3	5		N	Preferred Brand	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				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
H4513	060	3	1	01	01	H4513_060_3	5		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	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
H4513	060	3	1	01	01	H4513_060_3	5		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										35.00						35.00						35.00		35.00
H4513	060	4	1	01	01	H4513_060_4	5		N	Preferred Generic	4	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																			19.00	38.00	57.00																19.00				19.00		0.63			0.63			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00
H4513	060	4	1	01	01	H4513_060_4	5		N	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																			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
H4513	060	4	1	01	01	H4513_060_4	5		N	Preferred Brand	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				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
H4513	060	4	1	01	01	H4513_060_4	5		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	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
H4513	060	4	1	01	01	H4513_060_4	5		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										35.00						35.00						35.00		35.00
H4513	060	5	1	01	01	H4513_060_5	5		N	Preferred Generic	4	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																			19.00	38.00	57.00																19.00				19.00		0.63			0.63			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00
H4513	060	5	1	01	01	H4513_060_5	5		N	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																			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
H4513	060	5	1	01	01	H4513_060_5	5		N	Preferred Brand	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				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
H4513	060	5	1	01	01	H4513_060_5	5		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	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
H4513	060	5	1	01	01	H4513_060_5	5		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										35.00						35.00						35.00		35.00
H4513	061	1	1	01	01	H4513_061_1	4			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
H4513	061	1	1	01	01	H4513_061_1	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	061	1	1	01	01	H4513_061_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											826.20	33						620.06	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
H4513	061	2	1	01	01	H4513_061_2	4			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
H4513	061	2	1	01	01	H4513_061_2	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	061	2	1	01	01	H4513_061_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											826.20	33						620.06	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
H4513	061	3	1	01	01	H4513_061_3	4			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
H4513	061	3	1	01	01	H4513_061_3	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	061	3	1	01	01	H4513_061_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											826.20	33						620.06	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
H4513	061	4	1	01	01	H4513_061_4	4			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
H4513	061	4	1	01	01	H4513_061_4	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	061	4	1	01	01	H4513_061_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											826.20	33						620.06	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
H4513	061	5	1	01	01	H4513_061_5	4			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
H4513	061	5	1	01	01	H4513_061_5	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	061	5	1	01	01	H4513_061_5	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											826.20	33						620.06	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
H4513	064	0	1	01	01	H4513_064_0	4			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
H4513	064	0	1	01	01	H4513_064_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	064	0	1	01	01	H4513_064_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											796.28	33						663.35	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
H4513	068	1	1	01	01	H4513_068_1	4			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
H4513	068	1	1	01	01	H4513_068_1	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	068	1	1	01	01	H4513_068_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											908.55	33						638.56	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
H4513	068	2	1	01	01	H4513_068_2	4			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
H4513	068	2	1	01	01	H4513_068_2	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	068	2	1	01	01	H4513_068_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											908.55	33						638.56	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
H4513	068	3	1	01	01	H4513_068_3	4			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
H4513	068	3	1	01	01	H4513_068_3	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	068	3	1	01	01	H4513_068_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											908.55	33						638.56	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
H4513	073	0	1	01	01	H4513_073_0	5			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	073	0	1	01	01	H4513_073_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	073	0	1	01	01	H4513_073_0	5			Preferred Brand	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	5			Non-Preferred Drug	4	11	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	073	0	1	01	01	H4513_073_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											875.05	33						628.36	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
H4513	074	0	1	01	01	H4513_074_0	4			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
H4513	074	0	1	01	01	H4513_074_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	074	0	1	01	01	H4513_074_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											823.84	33						471.53	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
H4513	075	0	1	01	01	H4513_075_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								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										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
H4513	075	0	1	01	01	H4513_075_0	5		N	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	075	0	1	01	01	H4513_075_0	5		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	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	075	0	1	01	01	H4513_075_0	5		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	300.00											100.00	200.00	300.00				100.00	200.00	300.00				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	075	0	1	01	01	H4513_075_0	5		N	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
H4513	077	1	1	01	01	H4513_077_1	4			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
H4513	077	1	1	01	01	H4513_077_1	4			Generic	4	11	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
H4513	077	1	1	01	01	H4513_077_1	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	077	1	1	01	01	H4513_077_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											809.18	33						590.56	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
H4513	077	2	1	01	01	H4513_077_2	4			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
H4513	077	2	1	01	01	H4513_077_2	4			Generic	4	11	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
H4513	077	2	1	01	01	H4513_077_2	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	077	2	1	01	01	H4513_077_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											809.18	33						590.56	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
H4513	077	3	1	01	01	H4513_077_3	4			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
H4513	077	3	1	01	01	H4513_077_3	4			Generic	4	11	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
H4513	077	3	1	01	01	H4513_077_3	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	077	3	1	01	01	H4513_077_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											809.18	33						590.56	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
H4513	077	4	1	01	01	H4513_077_4	4			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
H4513	077	4	1	01	01	H4513_077_4	4			Generic	4	11	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
H4513	077	4	1	01	01	H4513_077_4	4			Preferred Brand	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	4	1	01	01	H4513_077_4	4			Non-Preferred Drug	4	11	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	077	4	1	01	01	H4513_077_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											809.18	33						590.56	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
H4513	083	1	1	01	01	H4513_083_1	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	083	1	1	01	01	H4513_083_1	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	083	1	1	01	01	H4513_083_1	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	083	1	1	01	01	H4513_083_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											881.90	33						618.78	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
H4513	083	2	1	01	01	H4513_083_2	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	083	2	1	01	01	H4513_083_2	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	083	2	1	01	01	H4513_083_2	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	083	2	1	01	01	H4513_083_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											881.90	33						618.78	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
H4513	083	3	1	01	01	H4513_083_3	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	083	3	1	01	01	H4513_083_3	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	083	3	1	01	01	H4513_083_3	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	083	3	1	01	01	H4513_083_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											881.90	33						618.78	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
H4513	083	4	1	01	01	H4513_083_4	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	083	4	1	01	01	H4513_083_4	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	083	4	1	01	01	H4513_083_4	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	083	4	1	01	01	H4513_083_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											881.90	33						618.78	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
H4513	083	5	1	01	01	H4513_083_5	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	083	5	1	01	01	H4513_083_5	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	083	5	1	01	01	H4513_083_5	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	083	5	1	01	01	H4513_083_5	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											881.90	33						618.78	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
H4513	083	6	1	01	01	H4513_083_6	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	083	6	1	01	01	H4513_083_6	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	083	6	1	01	01	H4513_083_6	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	083	6	1	01	01	H4513_083_6	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											881.90	33						618.78	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
H4513	083	7	1	01	01	H4513_083_7	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	083	7	1	01	01	H4513_083_7	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	083	7	1	01	01	H4513_083_7	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	083	7	1	01	01	H4513_083_7	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											881.90	33						618.78	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
H4513	084	0	1	02	01	H4513_084_0	4			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
H4513	084	0	1	02	01	H4513_084_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											901.97	33						951.51	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
H4513	085	0	1	01	01	H4513_085_0	4			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
H4513	085	0	1	01	01	H4513_085_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											886.74	33						718.01	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
H4513	086	0	1	01	01	H4513_086_0	4			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
H4513	086	0	1	01	01	H4513_086_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											886.74	33						718.01	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
H4513	087	1	1	01	01	H4513_087_1	4			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
H4513	087	1	1	01	01	H4513_087_1	4			Generic	4	11	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
H4513	087	1	1	01	01	H4513_087_1	4			Preferred Brand	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	087	1	1	01	01	H4513_087_1	4			Non-Preferred Drug	4	11	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	087	1	1	01	01	H4513_087_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											719.65	33						649.03	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
H4513	087	2	1	01	01	H4513_087_2	4			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
H4513	087	2	1	01	01	H4513_087_2	4			Generic	4	11	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
H4513	087	2	1	01	01	H4513_087_2	4			Preferred Brand	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	087	2	1	01	01	H4513_087_2	4			Non-Preferred Drug	4	11	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	087	2	1	01	01	H4513_087_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											719.65	33						649.03	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
H4513	087	3	1	01	01	H4513_087_3	4			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
H4513	087	3	1	01	01	H4513_087_3	4			Generic	4	11	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
H4513	087	3	1	01	01	H4513_087_3	4			Preferred Brand	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	087	3	1	01	01	H4513_087_3	4			Non-Preferred Drug	4	11	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	087	3	1	01	01	H4513_087_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											719.65	33						649.03	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
H4513	087	4	1	01	01	H4513_087_4	4			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
H4513	087	4	1	01	01	H4513_087_4	4			Generic	4	11	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
H4513	087	4	1	01	01	H4513_087_4	4			Preferred Brand	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	087	4	1	01	01	H4513_087_4	4			Non-Preferred Drug	4	11	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	087	4	1	01	01	H4513_087_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											719.65	33						649.03	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
H4513	088	0	1	01	01	H4513_088_0	4			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
H4513	088	0	1	01	01	H4513_088_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	088	0	1	01	01	H4513_088_0	4			Preferred Brand	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	088	0	1	01	01	H4513_088_0	4			Non-Preferred Drug	4	11	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	088	0	1	01	01	H4513_088_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											879.62	33						582.99	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
H4513	089	0	1	01	01	H4513_089_0	4			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
H4513	089	0	1	01	01	H4513_089_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	089	0	1	01	01	H4513_089_0	4			Preferred Brand	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	089	0	1	01	01	H4513_089_0	4			Non-Preferred Drug	4	11	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	089	0	1	01	01	H4513_089_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											879.62	33						582.99	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
H4513	090	0	1	01	01	H4513_090_0	4			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
H4513	090	0	1	01	01	H4513_090_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	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	090	0	1	01	01	H4513_090_0	4			Preferred Brand	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	090	0	1	01	01	H4513_090_0	4			Non-Preferred Drug	4	11	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	090	0	1	01	01	H4513_090_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											904.89	33						723.91	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
H4513	091	0	1	01	01	H4513_091_0	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	091	0	1	01	01	H4513_091_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	091	0	1	01	01	H4513_091_0	4			Preferred Brand	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	091	0	1	01	01	H4513_091_0	4			Non-Preferred Drug	4	11	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	091	0	1	01	01	H4513_091_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.67	33						617.70	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
H4513	092	0	1	01	01	H4513_092_0	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	092	0	1	01	01	H4513_092_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	092	0	1	01	01	H4513_092_0	4			Preferred Brand	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	092	0	1	01	01	H4513_092_0	4			Non-Preferred Drug	4	11	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	092	0	1	01	01	H4513_092_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.67	33						617.70	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
H4513	093	0	1	01	01	H4513_093_0	4			Preferred Generic	4	01	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										5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H4513	093	0	1	01	01	H4513_093_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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
H4513	093	0	1	01	01	H4513_093_0	4			Preferred Brand	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	093	0	1	01	01	H4513_093_0	4			Non-Preferred Drug	4	11	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	093	0	1	01	01	H4513_093_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.67	33						617.70	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				189.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				199.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				186.00	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
H4514	016	0	1	02	01	H4514_016_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																								
H4514	016	0	1	02	01	H4514_016_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																								
H4514	016	0	1	02	01	H4514_016_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				79.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H4514	016	0	1	02	01	H4514_016_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				38.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4514	016	0	1	02	01	H4514_016_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				175.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				193.00	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
H4514	022	0	1	02	01	H4514_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																								
H4514	022	0	1	02	01	H4514_022_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	022	0	1	02	01	H4514_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
H4514	022	0	1	02	01	H4514_022_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4514	022	0	1	02	01	H4514_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				194.00	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
H4523	001	0	1	01	01	H4523_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	001	0	1	01	01	H4523_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	001	0	1	01	01	H4523_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.22	24	24	24				108.23	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
H4523	001	0	1	01	01	H4523_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.98	25	25	25				35.92	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
H4523	001	0	1	01	01	H4523_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											859.86	25						866.69	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
H4523	015	0	1	01	01	H4523_015_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	015	0	1	01	01	H4523_015_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	015	0	1	01	01	H4523_015_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.17	24	24	24				109.08	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
H4523	015	0	1	01	01	H4523_015_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.42	25	25	25				37.68	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
H4523	015	0	1	01	01	H4523_015_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											907.05	25						692.84	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
H4523	020	0	1	01	01	H4523_020_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	020	0	1	01	01	H4523_020_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4523	020	0	1	01	01	H4523_020_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.06	25	25	25				88.07	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
H4523	020	0	1	01	01	H4523_020_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.42	35	35	35				34.19	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
H4523	020	0	1	01	01	H4523_020_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1114.73	33						976.51	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
H4523	021	0	1	01	01	H4523_021_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	021	0	1	01	01	H4523_021_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	021	0	1	01	01	H4523_021_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.41	24	24	24				116.44	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
H4523	021	0	1	01	01	H4523_021_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.27	25	25	25				35.23	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
H4523	021	0	1	01	01	H4523_021_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											880.23	25						762.48	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
H4523	024	0	1	01	01	H4523_024_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	024	0	1	01	01	H4523_024_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4523	024	0	1	01	01	H4523_024_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.39	25	25	25				95.68	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
H4523	024	0	1	01	01	H4523_024_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.63	35	35	35				30.91	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
H4523	024	0	1	01	01	H4523_024_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1134.78	33						1003.67	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
H4523	027	0	1	01	01	H4523_027_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	027	0	1	01	01	H4523_027_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	027	0	1	01	01	H4523_027_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.55	24	24	24				106.63	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
H4523	027	0	1	01	01	H4523_027_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.11	25	25	25				35.71	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
H4523	027	0	1	01	01	H4523_027_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											834.32	25						776.31	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
H4523	031	0	1	01	01	H4523_031_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	031	0	1	01	01	H4523_031_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4523	031	0	1	01	01	H4523_031_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.06	22	22	22				40.69	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	031	0	1	01	01	H4523_031_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.17	25	25	25				44.37	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
H4523	031	0	1	01	01	H4523_031_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											351.84	25						311.50	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
H4527	001	0	1	02	01	H4527_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																								
H4527	001	0	1	02	01	H4527_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																								
H4527	001	0	1	02	01	H4527_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
H4527	001	0	1	02	01	H4527_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	001	0	1	02	01	H4527_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				218.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				193.00	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
H4527	003	0	1	02	01	H4527_003_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																								
H4527	003	0	1	02	01	H4527_003_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																								
H4527	003	0	1	02	01	H4527_003_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				75.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H4527	003	0	1	02	01	H4527_003_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				42.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4527	003	0	1	02	01	H4527_003_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				166.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4527	005	0	1	02	01	H4527_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																								
H4527	005	0	1	02	01	H4527_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																								
H4527	005	0	1	02	01	H4527_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
H4527	005	0	1	02	01	H4527_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	005	0	1	02	01	H4527_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				224.00	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
H4527	013	0	1	02	01	H4527_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																								
H4527	013	0	1	02	01	H4527_013_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																								
H4527	013	0	1	02	01	H4527_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
H4527	013	0	1	02	01	H4527_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	013	0	1	02	01	H4527_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				209.00	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
H4527	037	0	1	02	01	H4527_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																								
H4527	037	0	1	02	01	H4527_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																								
H4527	037	0	1	02	01	H4527_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
H4527	037	0	1	02	01	H4527_037_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	037	0	1	02	01	H4527_037_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				202.00	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
H4527	039	0	1	02	01	H4527_039_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	039	0	1	02	01	H4527_039_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																								
H4527	039	0	1	02	01	H4527_039_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
H4527	039	0	1	02	01	H4527_039_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	039	0	1	02	01	H4527_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				170.00	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
H4527	040	0	1	02	01	H4527_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																								
H4527	040	0	1	02	01	H4527_040_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																								
H4527	040	0	1	02	01	H4527_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										25.00		75.00						75.00			65.00	25.00		25.00
H4527	040	0	1	02	01	H4527_040_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	040	0	1	02	01	H4527_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				206.00	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
H4527	041	0	1	02	01	H4527_041_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	041	0	1	02	01	H4527_041_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																								
H4527	041	0	1	02	01	H4527_041_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
H4527	041	0	1	02	01	H4527_041_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	041	0	1	02	01	H4527_041_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				203.00	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
H4527	042	0	1	02	01	H4527_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																								
H4527	042	0	1	02	01	H4527_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																								
H4527	042	0	1	02	01	H4527_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										25.00		75.00						75.00			65.00	25.00		25.00
H4527	042	0	1	02	01	H4527_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	042	0	1	02	01	H4527_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				234.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				158.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				199.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				195.00	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
H4527	052	0	1	02	01	H4527_052_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	052	0	1	02	01	H4527_052_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	052	0	1	02	01	H4527_052_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	052	0	1	02	01	H4527_052_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	052	0	1	02	01	H4527_052_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				188.00	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
H4527	053	0	1	02	01	H4527_053_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	053	0	1	02	01	H4527_053_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	053	0	1	02	01	H4527_053_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	053	0	1	02	01	H4527_053_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4527	053	0	1	02	01	H4527_053_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				181.00	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
H4537	001	0	1	04	01	H4537_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																								
H4537	001	0	1	04	01	H4537_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H4537	001	0	1	04	01	H4537_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											162.73	25	25	25				162.73	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
H4537	001	0	1	04	01	H4537_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											62.19	38	38	38				60.56	37	37	37										38	38	38				37	37	37			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
H4537	001	0	1	04	01	H4537_001_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, Select Care Drugs																								
H4537	001	0	1	04	01	H4537_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																								
H4544	001	0	1	04	01	H4544_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																								
H4544	001	0	1	04	01	H4544_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																								
H4544	001	0	1	04	01	H4544_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						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			105.00	35.00		35.00
H4544	001	0	1	04	01	H4544_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4544	001	0	1	04	01	H4544_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				195.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				172.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				180.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				170.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				173.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				196.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				177.00	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
H4604	017	0	1	02	01	H4604_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																								
H4604	017	0	1	02	01	H4604_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																								
H4604	017	0	1	02	01	H4604_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
H4604	017	0	1	02	01	H4604_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4604	017	0	1	02	01	H4604_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				150.00	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
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			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.50	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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		141.00													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		105.00			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		010	01		010	1				30			2	2				30			30		31								100.00							100.00													100.00						100.00						100.00				100.00			3.33	3.33		3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			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											93.00	28						226.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				133.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				197.00	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
H4604	024	0	1	02	01	H4604_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																								
H4604	024	0	1	02	01	H4604_024_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																								
H4604	024	0	1	02	01	H4604_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										25.00		75.00						75.00			65.00	25.00		25.00
H4604	024	0	1	02	01	H4604_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4604	024	0	1	02	01	H4604_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
H4604	025	0	1	02	01	H4604_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																								
H4604	025	0	1	02	01	H4604_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																								
H4604	025	0	1	02	01	H4604_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										25.00		75.00						75.00			65.00	25.00		25.00
H4604	025	0	1	02	01	H4604_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4604	025	0	1	02	01	H4604_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H4604	027	0	1	02	01	H4604_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																								
H4604	027	0	1	02	01	H4604_027_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																								
H4604	027	0	1	02	01	H4604_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
H4604	027	0	1	02	01	H4604_027_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4604	027	0	1	02	01	H4604_027_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				242.00	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
H4604	028	0	1	02	01	H4604_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																								
H4604	028	0	1	02	01	H4604_028_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	028	0	1	02	01	H4604_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
H4604	028	0	1	02	01	H4604_028_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H4604	028	0	1	02	01	H4604_028_0	5			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										35.00						35.00			35.00			35.00		35.00
H4605	002	0	1	04	01	H4605_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								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H4605	002	0	1	04	01	H4605_002_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					5.00	10.00	10.00											13.00	26.00	26.00				5.00	10.00	10.00				13.00				13.00			0.43	0.17		0.43	0.17	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	5.00	10.00	10.00	13.00	26.00	26.00	5.00	10.00	10.00	13.00		13.00
H4605	002	0	1	04	01	H4605_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											56.08	25	25	25				56.08	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H4605	002	0	1	04	01	H4605_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											60.67	43	43	43				60.67	40	40	40										43	43	43				40	40	40			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
H4605	002	0	1	04	01	H4605_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											915.32	31						915.32	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4605	004	0	1	04	01	H4605_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								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H4605	004	0	1	04	01	H4605_004_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					4.00	8.00	8.00											13.00	26.00	26.00				4.00	8.00	8.00				13.00				13.00			0.43	0.13		0.43	0.13	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	4.00	8.00	8.00	13.00	26.00	26.00	4.00	8.00	8.00	13.00		13.00
H4605	004	0	1	04	01	H4605_004_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											60.25	25	25	25				60.25	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H4605	004	0	1	04	01	H4605_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											73.78	43	43	43				73.78	40	40	40										43	43	43				40	40	40			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
H4605	004	0	1	04	01	H4605_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											931.27	33						931.27	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4618	001	0	1	04	01	H4618_001_0	7			Preferred Generic	4	01	1	2	1	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																								
H4618	001	0	1	04	01	H4618_001_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				1	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										10.00		30.00						0.00				10.00		10.00
H4618	001	0	1	04	01	H4618_001_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				1	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
H4618	001	0	1	04	01	H4618_001_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										35.00		70.00						70.00				35.00		35.00
H4618	001	0	1	04	01	H4618_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																								
H4620	001	0	1	04	01	H4620_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 Drug, 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	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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
H4620	001	0	1	04	01	H4620_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					47.00	94.00	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	105.00			105.00				35.00		35.00
H4620	001	0	1	04	01	H4620_001_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											73.24	46	46	46				66.80	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			105.00				35.00		35.00
H4620	001	0	1	04	01	H4620_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 Drug, Specialty Tier										35.00			35.00			35.00						35.00		35.00
H4623	001	0	1	02	01	H4623_001_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
H4623	001	0	1	02	01	H4623_001_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
H4623	001	0	1	02	01	H4623_001_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		95.00	35.00		35.00
H4623	001	0	1	02	01	H4623_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H4623	001	0	1	02	01	H4623_001_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
H4623	002	0	1	02	01	H4623_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
H4623	002	0	1	02	01	H4623_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
H4623	002	0	1	02	01	H4623_002_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		60.00				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		60.00	30.00		30.00
H4623	002	0	1	02	01	H4623_002_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				56.00	35		35																								50		50				35		35			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
H4623	002	0	1	02	01	H4623_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
H4624	001	0	1	01	01	H4624_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	6			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	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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, 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	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				94.53	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
H4624	001	0	1	01	01	H4624_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				562.61	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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			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										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			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	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
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				586.54	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	006	0	1	01	01	H4624_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	7			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	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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				83.06	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
H4624	006	0	1	01	01	H4624_006_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				573.79	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	010	0	1	01	01	H4624_010_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	010	0	1	01	01	H4624_010_0	7			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	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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				97.68	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H4624	010	0	1	01	01	H4624_010_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				674.03	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
H4624	010	0	1	01	01	H4624_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																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	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, 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	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				74.73	33	33	33																		33	33	33															33			33								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
H4624	011	0	1	01	01	H4624_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				534.48	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
H4624	011	0	1	01	01	H4624_011_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
H4624	012	0	1	01	01	H4624_012_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, 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	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				77.53	33	33	33																		33	33	33															33			33								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
H4624	012	0	1	01	01	H4624_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				509.46	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
H4624	012	0	1	01	01	H4624_012_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
H4624	019	0	1	01	01	H4624_019_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	019	0	1	01	01	H4624_019_0	10		N	Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				10.00	20	20	20																		0	0	0															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4624	019	0	1	01	01	H4624_019_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				10.00	25	25	25																		25	25	25															25			25								Preferred Generic, 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	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				69.72	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	70.00				35.00		35.00
H4624	019	0	1	01	01	H4624_019_0	10		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				451.97	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	022	0	1	01	01	H4624_022_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
H4624	022	0	1	01	01	H4624_022_0	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				81.07	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
H4624	022	0	1	01	01	H4624_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				562.89	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	023	0	1	01	01	H4624_023_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, 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	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				72.05	33	33	33																		33	33	33															33			33								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
H4624	023	0	1	01	01	H4624_023_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				534.32	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
H4624	023	0	1	01	01	H4624_023_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
H4624	024	0	1	01	01	H4624_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, 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	7			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																								
H4624	024	0	1	01	01	H4624_024_0	7			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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				67.79	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	70.00				35.00		35.00
H4624	024	0	1	01	01	H4624_024_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				463.90	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00						0.00						0.00		0.00
H4624	024	0	1	01	01	H4624_024_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										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	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	025	0	1	01	01	H4624_025_0	7			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	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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				71.27	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H4624	025	0	1	01	01	H4624_025_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				529.89	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
H4624	025	0	1	01	01	H4624_025_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										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	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
H4624	026	0	1	01	01	H4624_026_0	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				81.75	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
H4624	026	0	1	01	01	H4624_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				570.90	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	027	0	1	01	01	H4624_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, 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	7			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																								
H4624	027	0	1	01	01	H4624_027_0	7			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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				67.04	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	70.00				35.00		35.00
H4624	027	0	1	01	01	H4624_027_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				460.67	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00						0.00						0.00		0.00
H4624	027	0	1	01	01	H4624_027_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										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	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, 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	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				75.25	33	33	33																		33	33	33															33			33								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
H4624	028	0	1	01	01	H4624_028_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				555.33	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
H4624	028	0	1	01	01	H4624_028_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
H4624	029	0	1	01	01	H4624_029_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	Preferred 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	029	0	1	01	01	H4624_029_0	6			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	029	0	1	01	01	H4624_029_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	029	0	1	01	01	H4624_029_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				72.53	33	33	33																		33	33	33															33			33								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
H4624	029	0	1	01	01	H4624_029_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				537.69	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
H4624	029	0	1	01	01	H4624_029_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	Preferred 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	030	0	1	01	01	H4624_030_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	Preferred Generic, 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	030	0	1	01	01	H4624_030_0	6			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																								
H4624	030	0	1	01	01	H4624_030_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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, 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	030	0	1	01	01	H4624_030_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				84.36	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
H4624	030	0	1	01	01	H4624_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				578.58	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	031	0	1	01	01	H4624_031_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	Preferred 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	031	0	1	01	01	H4624_031_0	6			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	031	0	1	01	01	H4624_031_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	031	0	1	01	01	H4624_031_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				71.54	33	33	33																		33	33	33															33			33								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
H4624	031	0	1	01	01	H4624_031_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				515.00	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
H4624	031	0	1	01	01	H4624_031_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	Preferred 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	032	0	1	01	01	H4624_032_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	Preferred 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	032	0	1	01	01	H4624_032_0	6			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	032	0	1	01	01	H4624_032_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	032	0	1	01	01	H4624_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				71.14	33	33	33																		33	33	33															33			33								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
H4624	032	0	1	01	01	H4624_032_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				71.14	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
H4624	032	0	1	01	01	H4624_032_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	Preferred 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	033	0	1	01	01	H4624_033_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	033	0	1	01	01	H4624_033_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, Select Care Drugs																								
H4624	033	0	1	01	01	H4624_033_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	033	0	1	01	01	H4624_033_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				69.16	33	33	33																		33	33	33															33			33								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
H4624	033	0	1	01	01	H4624_033_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				475.60	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
H4624	033	0	1	01	01	H4624_033_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	034	0	1	01	01	H4624_034_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	Preferred 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	034	0	1	01	01	H4624_034_0	6			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	034	0	1	01	01	H4624_034_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	034	0	1	01	01	H4624_034_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				69.16	33	33	33																		33	33	33															33			33								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
H4624	034	0	1	01	01	H4624_034_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				475.62	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
H4624	034	0	1	01	01	H4624_034_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	Preferred 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	035	0	1	01	01	H4624_035_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	035	0	1	01	01	H4624_035_0	7			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																								
H4624	035	0	1	01	01	H4624_035_0	7			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	035	0	1	01	01	H4624_035_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				68.08	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	70.00				35.00		35.00
H4624	035	0	1	01	01	H4624_035_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				464.81	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00						0.00						0.00		0.00
H4624	035	0	1	01	01	H4624_035_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	036	0	1	01	01	H4624_036_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	Preferred 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	036	0	1	01	01	H4624_036_0	6			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	036	0	1	01	01	H4624_036_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	036	0	1	01	01	H4624_036_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				72.53	33	33	33																		33	33	33															33			33								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
H4624	036	0	1	01	01	H4624_036_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				537.68	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
H4624	036	0	1	01	01	H4624_036_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	Preferred 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	037	0	1	01	01	H4624_037_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	Preferred Generic, 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	037	0	1	01	01	H4624_037_0	6			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	037	0	1	01	01	H4624_037_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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, 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	037	0	1	01	01	H4624_037_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				82.16	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
H4624	037	0	1	01	01	H4624_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				569.12	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	038	0	1	01	01	H4624_038_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	038	0	1	01	01	H4624_038_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	038	0	1	01	01	H4624_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																			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	038	0	1	01	01	H4624_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				82.16	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
H4624	038	0	1	01	01	H4624_038_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				569.11	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	039	0	1	01	01	H4624_039_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	Preferred 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	039	0	1	01	01	H4624_039_0	6			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	039	0	1	01	01	H4624_039_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	039	0	1	01	01	H4624_039_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				70.73	33	33	33																		33	33	33															33			33								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
H4624	039	0	1	01	01	H4624_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				502.96	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
H4624	039	0	1	01	01	H4624_039_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	Preferred 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	040	0	1	01	01	H4624_040_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	Preferred 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	040	0	1	01	01	H4624_040_0	6			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	040	0	1	01	01	H4624_040_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	040	0	1	01	01	H4624_040_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				70.73	33	33	33																		33	33	33															33			33								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
H4624	040	0	1	01	01	H4624_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				502.98	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
H4624	040	0	1	01	01	H4624_040_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	Preferred 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	041	0	1	01	01	H4624_041_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	041	0	1	01	01	H4624_041_0	10			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																								
H4624	041	0	1	01	01	H4624_041_0	10			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	041	0	1	01	01	H4624_041_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				68.08	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	70.00				35.00		35.00
H4624	041	0	1	01	01	H4624_041_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				464.83	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00						0.00						0.00		0.00
H4624	041	0	1	01	01	H4624_041_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	042	0	1	01	01	H4624_042_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	Preferred 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	042	0	1	01	01	H4624_042_0	6			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	042	0	1	01	01	H4624_042_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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	042	0	1	01	01	H4624_042_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				72.53	33	33	33																		33	33	33															33			33								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
H4624	042	0	1	01	01	H4624_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				537.68	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
H4624	042	0	1	01	01	H4624_042_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	Preferred 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	043	0	1	01	01	H4624_043_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	Preferred Generic, 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	043	0	1	01	01	H4624_043_0	6			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	043	0	1	01	01	H4624_043_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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, 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	043	0	1	01	01	H4624_043_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				82.47	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
H4624	043	0	1	01	01	H4624_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				570.92	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4624	044	0	1	01	01	H4624_044_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	Preferred Generic, 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	044	0	1	01	01	H4624_044_0	6			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	044	0	1	01	01	H4624_044_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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, 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	044	0	1	01	01	H4624_044_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				82.46	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
H4624	044	0	1	01	01	H4624_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				570.90	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H4647	001	0	1	01	01	H4647_001_0	8			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																								
H4647	001	0	1	01	01	H4647_001_0	8			Generic	4	01	1	2	2	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4647	001	0	1	01	01	H4647_001_0	8			Preferred Brand	4	11	3	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	82.25	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	61.25	87.50				35.00		35.00
H4647	001	0	1	01	01	H4647_001_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				58.47	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	61.25	87.50				35.00		35.00
H4647	001	0	1	01	01	H4647_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				733.55	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4647	002	0	1	01	01	H4647_002_0	8			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																								
H4647	002	0	1	01	01	H4647_002_0	8			Generic	4	01	1	2	2	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4647	002	0	1	01	01	H4647_002_0	8			Preferred Brand	4	11	3	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	82.25	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	61.25	87.50				35.00		35.00
H4647	002	0	1	01	01	H4647_002_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				58.47	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	61.25	87.50				35.00		35.00
H4647	002	0	1	01	01	H4647_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				733.55	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4661	001	0	1	02	01	H4661_001_0	5			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																								
H4661	001	0	1	02	01	H4661_001_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.39	25	25	25				161.39	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
H4661	001	0	1	02	01	H4661_001_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											47.04	36	36	36				47.04	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
H4661	001	0	1	02	01	H4661_001_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, Select Care Drugs																								
H4661	001	0	1	02	01	H4661_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	0.00				0.00				0.00			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	7			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																								
H4676	001	0	1	01	01	H4676_001_0	7			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										20.00	40.00	60.00	5.00	10.00	15.00							20.00		20.00
H4676	001	0	1	01	01	H4676_001_0	7			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										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	7			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										35.00	70.00	105.00	35.00	70.00	105.00							35.00		35.00
H4676	001	0	1	01	01	H4676_001_0	7			Specialty Tier	4	11	1	1	5	1		111	01			1				30	60	90	2	1							30		31											636.73	33	33	33				676.08	33	33	33																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines																								
H4676	001	0	1	01	01	H4676_001_0	7			Vaccines	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																								
H4676	002	0	1	01	01	H4676_002_0	7		N	Preferred Generic	4	11	1	2	1	1	111		01			1	30	60	90				2	1							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																								
H4676	002	0	1	01	01	H4676_002_0	7		N	Generic	4	11	1	1	2	1	111		01			1	30	60	90				2	1							30		31				7.31	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines										35.00	70.00	105.00										35.00		35.00
H4676	002	0	1	01	01	H4676_002_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01			1	30	60	90				2	1							30		31				108.45	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines										35.00	70.00	105.00										35.00		35.00
H4676	002	0	1	01	01	H4676_002_0	7		N	Non-Preferred Brand	4	11	1	1	4	1	111		01			1	30	60	90				2	1							30		31				58.76	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines										35.00	70.00	105.00										35.00		35.00
H4676	002	0	1	01	01	H4676_002_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01			1	30	60	90				2	1							30		31				489.13	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines																								
H4676	002	0	1	01	01	H4676_002_0	7		N	Vaccines	4	11	1	2	6	1	010		01			1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines																								
H4711	001	0	1	02	01	H4711_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	001	0	1	02	01	H4711_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	001	0	1	02	01	H4711_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.88	24	24	24				107.72	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
H4711	001	0	1	02	01	H4711_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.71	25	25	25				37.29	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
H4711	001	0	1	02	01	H4711_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.72	25						952.14	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
H4711	002	0	1	02	01	H4711_002_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	002	0	1	02	01	H4711_002_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	002	0	1	02	01	H4711_002_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.67	24	24	24				99.64	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
H4711	002	0	1	02	01	H4711_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.54	25	25	25				37.06	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
H4711	002	0	1	02	01	H4711_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											877.62	25						830.73	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
H4711	005	0	1	02	01	H4711_005_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	005	0	1	02	01	H4711_005_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	005	0	1	02	01	H4711_005_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.82	24	24	24				110.59	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
H4711	005	0	1	02	01	H4711_005_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											51.54	25	25	25				36.96	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
H4711	005	0	1	02	01	H4711_005_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											856.35	25						783.76	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
H4711	008	0	1	02	01	H4711_008_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	008	0	1	02	01	H4711_008_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4711	008	0	1	02	01	H4711_008_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.30	24	24	24				107.58	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
H4711	008	0	1	02	01	H4711_008_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.93	25	25	25				39.43	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
H4711	008	0	1	02	01	H4711_008_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											694.77	25						811.81	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
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					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																								
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																								
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					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
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											36.59	32	32	32				34.07	31	31	31										32	32	32				31	31	31			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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											100.77	30						105.79	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
H4754	018	0	1	04	01	H4754_018_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																								
H4754	018	0	1	04	01	H4754_018_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																								
H4754	018	0	1	04	01	H4754_018_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	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
H4754	018	0	1	04	01	H4754_018_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											23.08	30	30	30				22.21	29	29	29										30	30	30				29	29	29			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4754	018	0	1	04	01	H4754_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											119.64	26						139.00	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
H4801	002	0	1	04	01	H4801_002_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	002	0	1	04	01	H4801_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	002	0	1	04	01	H4801_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	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	002	0	1	04	01	H4801_002_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											98.80	37	37	37				99.85	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
H4801	002	0	1	04	01	H4801_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											569.42	30						442.60	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	007	0	1	04	01	H4801_007_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	007	0	1	04	01	H4801_007_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	007	0	1	04	01	H4801_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.66	50	50	50				92.21	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	105.00	35.00		35.00
H4801	007	0	1	04	01	H4801_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											613.73	30						645.55	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	011	0	1	04	01	H4801_011_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	011	0	1	04	01	H4801_011_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	011	0	1	04	01	H4801_011_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	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	011	0	1	04	01	H4801_011_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											97.25	31	31	31				83.27	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
H4801	011	0	1	04	01	H4801_011_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											646.32	33						582.74	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	015	0	1	04	01	H4801_015_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	015	0	1	04	01	H4801_015_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	015	0	1	04	01	H4801_015_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	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	015	0	1	04	01	H4801_015_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											102.78	25	25	25				100.66	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
H4801	015	0	1	04	01	H4801_015_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											410.89	25						410.62	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	016	0	1	04	01	H4801_016_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	016	0	1	04	01	H4801_016_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	016	0	1	04	01	H4801_016_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	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	016	0	1	04	01	H4801_016_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											99.48	35	35	35				99.91	30	30	30										35	35	35				30	30	30			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
H4801	016	0	1	04	01	H4801_016_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											469.83	25						437.28	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	018	0	1	04	01	H4801_018_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	018	0	1	04	01	H4801_018_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	018	0	1	04	01	H4801_018_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	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	018	0	1	04	01	H4801_018_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											101.42	25	25	25				90.09	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
H4801	018	0	1	04	01	H4801_018_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											557.57	25						391.73	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	021	0	1	04	01	H4801_021_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	021	0	1	04	01	H4801_021_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	021	0	1	04	01	H4801_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								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	021	0	1	04	01	H4801_021_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											99.32	25	25	25				93.84	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
H4801	021	0	1	04	01	H4801_021_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											470.89	25						434.97	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	022	0	1	04	01	H4801_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	022	0	1	04	01	H4801_022_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	022	0	1	04	01	H4801_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					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	022	0	1	04	01	H4801_022_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											111.23	25	25	25				93.68	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
H4801	022	0	1	04	01	H4801_022_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											389.74	25						383.61	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	023	0	1	04	01	H4801_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	023	0	1	04	01	H4801_023_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	023	0	1	04	01	H4801_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	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	023	0	1	04	01	H4801_023_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											94.90	50	50	50				99.94	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
H4801	023	0	1	04	01	H4801_023_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											562.12	30						528.37	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4801	024	0	1	04	01	H4801_024_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H4801	024	0	1	04	01	H4801_024_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H4801	024	0	1	04	01	H4801_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								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	024	0	1	04	01	H4801_024_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											71.23	50	50	50				77.18	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
H4801	024	0	1	04	01	H4801_024_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											593.67	33						589.65	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4808	001	0	1	04	01	H4808_001_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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
H4808	001	0	1	04	01	H4808_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				37.00	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
H4808	001	0	1	04	01	H4808_001_0	7			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
H4808	002	0	1	04	01	H4808_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				74.00	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
H4808	002	0	1	04	01	H4808_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				40.00	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
H4808	002	0	1	04	01	H4808_002_0	7			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
H4808	003	0	1	04	01	H4808_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H4808	003	0	1	04	01	H4808_003_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				37.00	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
H4808	003	0	1	04	01	H4808_003_0	7			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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	001	0	1	02	01	H4835_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	001	0	1	02	01	H4835_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.25	24	24	24				109.91	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
H4835	001	0	1	02	01	H4835_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.08	25	25	25				39.64	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
H4835	001	0	1	02	01	H4835_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											675.13	25						897.64	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
H4835	002	0	1	02	01	H4835_002_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	002	0	1	02	01	H4835_002_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	002	0	1	02	01	H4835_002_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.31	24	24	24				100.88	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
H4835	002	0	1	02	01	H4835_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.32	25	25	25				36.10	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
H4835	002	0	1	02	01	H4835_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											872.64	25						869.06	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
H4835	004	0	1	02	01	H4835_004_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	004	0	1	02	01	H4835_004_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	004	0	1	02	01	H4835_004_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.81	24	24	24				108.04	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
H4835	004	0	1	02	01	H4835_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.90	25	25	25				34.46	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
H4835	004	0	1	02	01	H4835_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											745.30	25						823.74	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
H4835	005	0	1	02	01	H4835_005_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	005	0	1	02	01	H4835_005_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4835	005	0	1	02	01	H4835_005_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.52	24	24	24				104.76	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
H4835	005	0	1	02	01	H4835_005_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.08	25	25	25				36.22	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
H4835	005	0	1	02	01	H4835_005_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											911.60	25						900.44	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
H4847	001	0	1	02	01	H4847_001_0	5			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	02	01	H4847_001_0	5			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																								
H4847	001	0	1	02	01	H4847_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.69	25	25	25				164.69	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
H4847	001	0	1	02	01	H4847_001_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											53.20	34	34	34				53.20	34	34	34										34	34	34				34	34	34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	02	01	H4847_001_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, Select Care Drugs																								
H4847	001	0	1	02	01	H4847_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4847	005	0	1	02	01	H4847_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					10.00	20.00	30.00											19.00	38.00	57.00				10.00	20.00	0.00				19.00				19.00			0.63	0.33		0.63	0.33	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4847	005	0	1	02	01	H4847_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4847	005	0	1	02	01	H4847_005_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											134.83	22	22	22				134.83	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
H4847	005	0	1	02	01	H4847_005_0	5			Non-Preferred Drug	3	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	200.00				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
H4847	005	0	1	02	01	H4847_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																								
H4847	005	0	1	02	01	H4847_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																								
H4868	016	0	1	02	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4868	016	0	1	02	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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4868	016	0	1	02	01	H4868_016_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											136.11	25	25	25				130.67	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
H4868	016	0	1	02	01	H4868_016_0	6			Non-Preferred Drug	3	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	200.00				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
H4868	016	0	1	02	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																								
H4868	016	0	1	02	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								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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H4868	019	0	1	02	01	H4868_019_0	5			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	02	01	H4868_019_0	5			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																								
H4868	019	0	1	02	01	H4868_019_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											145.71	25	25	25				145.71	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
H4868	019	0	1	02	01	H4868_019_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											70.67	36	36	36				70.67	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
H4868	019	0	1	02	01	H4868_019_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, Select Care Drugs																								
H4868	019	0	1	02	01	H4868_019_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																								
H4869	001	0	1	02	01	H4869_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 Brand, Specialty Tier, Select Diabetic Drugs																								
H4869	001	0	1	02	01	H4869_001_0	9			Generic	4	01	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 Brand, Specialty Tier, Select Diabetic Drugs																								
H4869	001	0	1	02	01	H4869_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	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																								
H4869	001	0	1	02	01	H4869_001_0	9			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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4869	001	0	1	02	01	H4869_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	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	9			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			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			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																								
H4869	003	0	1	02	01	H4869_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	117.00																			40.00	40.00	40.00																47.00				47.00		1.57			1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H4869	003	0	1	02	01	H4869_003_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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4869	003	0	1	02	01	H4869_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	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	005	0	1	02	01	H4869_005_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 Brand, Specialty Tier																								
H4869	005	0	1	02	01	H4869_005_0	9			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										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	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	117.00																			40.00	40.00	40.00																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	35.00	35.00				35.00		35.00
H4869	005	0	1	02	01	H4869_005_0	9			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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4869	005	0	1	02	01	H4869_005_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1000.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H4869	011	0	1	02	01	H4869_011_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	011	0	1	02	01	H4869_011_0	10			Generic	4	01	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 Brand, Specialty Tier, Select Diabetic Drugs																								
H4869	011	0	1	02	01	H4869_011_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	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																								
H4869	011	0	1	02	01	H4869_011_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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4869	011	0	1	02	01	H4869_011_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H4869	011	0	1	02	01	H4869_011_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	013	0	1	02	01	H4869_013_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	013	0	1	02	01	H4869_013_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																								
H4869	013	0	1	02	01	H4869_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	117.00																			40.00	40.00	40.00																47.00				47.00		1.57			1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H4869	013	0	1	02	01	H4869_013_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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4869	013	0	1	02	01	H4869_013_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1246.24	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																								
H4869	013	0	1	02	01	H4869_013_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
H4875	016	1	1	04	01	H4875_016_1	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					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	5			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																								
H4875	016	1	1	04	01	H4875_016_1	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.88	25	25	25				97.40	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
H4875	016	1	1	04	01	H4875_016_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.96	50	50	50				18.82	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
H4875	016	1	1	04	01	H4875_016_1	5			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	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					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	5			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																								
H4875	016	2	1	04	01	H4875_016_2	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.88	25	25	25				97.40	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
H4875	016	2	1	04	01	H4875_016_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.96	50	50	50				18.82	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
H4875	016	2	1	04	01	H4875_016_2	5			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	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					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	5			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																								
H4875	016	3	1	04	01	H4875_016_3	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.88	25	25	25				97.40	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
H4875	016	3	1	04	01	H4875_016_3	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.96	50	50	50				18.82	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
H4875	016	3	1	04	01	H4875_016_3	5			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	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					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	5			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																								
H4875	016	4	1	04	01	H4875_016_4	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.88	25	25	25				97.40	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
H4875	016	4	1	04	01	H4875_016_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.96	50	50	50				18.82	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
H4875	016	4	1	04	01	H4875_016_4	5			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	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					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	5			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																								
H4875	016	5	1	04	01	H4875_016_5	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.88	25	25	25				97.40	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
H4875	016	5	1	04	01	H4875_016_5	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.96	50	50	50				18.82	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
H4875	016	5	1	04	01	H4875_016_5	5			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	01	3	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																								
H4875	018	1	1	04	01	H4875_018_1	6			Preferred Brand	4	10	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.40	25	25	25				92.66	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
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											18.88	45	45	45				15.68	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
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	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	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	01	3	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																								
H4875	018	2	1	04	01	H4875_018_2	6			Preferred Brand	4	10	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.40	25	25	25				92.66	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
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											18.88	45	45	45				15.68	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
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	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	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	01	3	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																								
H4875	018	3	1	04	01	H4875_018_3	6			Preferred Brand	4	10	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.40	25	25	25				92.66	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
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											18.88	45	45	45				15.68	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
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	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	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	01	3	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																								
H4875	018	4	1	04	01	H4875_018_4	6			Preferred Brand	4	10	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.40	25	25	25				92.66	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
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											18.88	45	45	45				15.68	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
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	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	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	01	3	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																								
H4875	018	5	1	04	01	H4875_018_5	6			Preferred Brand	4	10	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.40	25	25	25				92.66	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
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											18.88	45	45	45				15.68	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
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	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	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																								
H4875	020	1	1	04	01	H4875_020_1	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.15	25	25	25				98.19	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
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											16.11	45	45	45				14.35	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																								
H4875	020	2	1	04	01	H4875_020_2	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.15	25	25	25				98.19	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
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											16.11	45	45	45				14.35	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																								
H4875	020	3	1	04	01	H4875_020_3	6			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.15	25	25	25				98.19	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
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											16.11	45	45	45				14.35	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	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																								
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											31.41	50	50	50				21.86	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	28						1.00	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
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																								
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											31.41	50	50	50				21.86	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	28						1.00	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
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																								
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											31.41	50	50	50				21.86	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	28						1.00	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
H4875	024	1	1	04	01	H4875_024_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					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	024	1	1	04	01	H4875_024_1	6			Generic	4	11	3	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																								
H4875	024	1	1	04	01	H4875_024_1	6			Preferred Brand	4	10	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.69	25	25	25				104.60	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
H4875	024	1	1	04	01	H4875_024_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											17.78	50	50	50				16.75	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	024	1	1	04	01	H4875_024_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	024	2	1	04	01	H4875_024_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					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	024	2	1	04	01	H4875_024_2	6			Generic	4	11	3	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																								
H4875	024	2	1	04	01	H4875_024_2	6			Preferred Brand	4	10	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.69	25	25	25				104.60	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
H4875	024	2	1	04	01	H4875_024_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											17.78	50	50	50				16.75	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	024	2	1	04	01	H4875_024_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
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	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				47.00	20		20																								20		20				20		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		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				67.97	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		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				885.07	29																										29						29					29			29								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	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				86.47	50		50																								50		50				50		48			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
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				403.38	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			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			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				47.00	20		20																								20		20				20		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		35.00
H4882	005	0	1	04	01	H4882_005_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				91.50	50		50																								50		50				50		48			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
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				527.39	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4882	009	1	1	04	01	H4882_009_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	009	1	1	04	01	H4882_009_1	7			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	009	1	1	04	01	H4882_009_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	009	1	1	04	01	H4882_009_1	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				96.47	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
H4882	009	1	1	04	01	H4882_009_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				660.94	29																										29						29					29			29								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	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	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				96.47	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
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				660.94	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4882	010	1	1	04	01	H4882_010_1	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	010	1	1	04	01	H4882_010_1	9			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	9			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				47.00	20		20																								20		20				20		18			20			20								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	9			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				78.71	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
H4882	010	1	1	04	01	H4882_010_1	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				605.26	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4882	010	2	1	04	01	H4882_010_2	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				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	10			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	10			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				47.00	20		20																								20		20				20		18			20			20								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	10			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				78.71	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
H4882	010	2	1	04	01	H4882_010_2	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				605.26	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4882	011	1	1	04	01	H4882_011_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	011	1	1	04	01	H4882_011_1	7			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	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	011	1	1	04	01	H4882_011_1	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				95.06	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
H4882	011	1	1	04	01	H4882_011_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				667.30	29																										29						29					29			29								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				95.06	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
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				667.30	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4882	013	0	1	04	01	H4882_013_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				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4882	013	0	1	04	01	H4882_013_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	8.00		24.00																									8.00		24.00				8.00		16.00				8.00				8.00		0.27				0.27	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										8.00		24.00				8.00		24.00	8.00		16.00	8.00		8.00
H4882	013	0	1	04	01	H4882_013_0	8			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				47.00	20		20																								20		20				20		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		35.00
H4882	013	0	1	04	01	H4882_013_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				97.95	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
H4882	013	0	1	04	01	H4882_013_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				600.86	25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4909	014	0	1	04	01	H4909_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								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	014	0	1	04	01	H4909_014_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H4909	014	0	1	04	01	H4909_014_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.27	20	20	20				58.27	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	70.00				35.00		35.00
H4909	014	0	1	04	01	H4909_014_0	7			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	35	35	35				49.64	35	35	35				35	35	35															35			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
H4909	014	0	1	04	01	H4909_014_0	7			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																								
H4909	014	0	1	04	01	H4909_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																								
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								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																								
H4909	026	0	1	04	01	H4909_026_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											61.72	20	20	20				61.72	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	70.00				35.00		35.00
H4909	026	0	1	04	01	H4909_026_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.04	35	35	35				56.04	35	35	35				35	35	35															35			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
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												29							29						29																	29			29								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	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																								
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			Generic	4	01	3	2	2	1		111	01	100		1				30	60	100	2	2			100				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			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	100	2	2			100				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	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																								
H4937	002	0	1	04	01	H4937_002_0	7			Generic	4	01	3	2	2	1		111	01	100		1				30	60	100	2	2			100				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	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	7			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	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	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																								
H4943	001	0	1	01	01	H4943_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								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
H4943	001	0	1	01	01	H4943_001_0	12			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	12			Preferred Brand	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	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	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	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																								
H4961	001	0	1	04	01	H4961_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
H4961	001	0	1	04	01	H4961_001_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	001	0	1	04	01	H4961_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
H4961	001	0	1	04	01	H4961_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
H4961	001	0	1	04	01	H4961_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				741.92	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	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	003	0	1	04	01	H4961_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, 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	8			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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				710.30	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	8			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	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				533.53	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																								
H4982	001	0	1	02	01	H4982_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	001	0	1	02	01	H4982_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	001	0	1	02	01	H4982_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											114.45	24	24	24				124.04	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
H4982	001	0	1	02	01	H4982_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.94	25	25	25				45.48	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
H4982	001	0	1	02	01	H4982_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											751.64	25						921.13	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
H4982	002	0	1	02	01	H4982_002_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	002	0	1	02	01	H4982_002_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	002	0	1	02	01	H4982_002_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											99.32	24	24	24				107.56	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
H4982	002	0	1	02	01	H4982_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.62	25	25	25				42.37	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
H4982	002	0	1	02	01	H4982_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											804.44	25						744.15	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
H4982	003	0	1	02	01	H4982_003_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	003	0	1	02	01	H4982_003_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	003	0	1	02	01	H4982_003_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.52	24	24	24				104.17	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
H4982	003	0	1	02	01	H4982_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.26	25	25	25				30.21	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
H4982	003	0	1	02	01	H4982_003_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											820.68	25						895.87	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
H4982	004	0	1	02	01	H4982_004_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	004	0	1	02	01	H4982_004_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	004	0	1	02	01	H4982_004_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.62	24	24	24				114.75	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
H4982	004	0	1	02	01	H4982_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.70	25	25	25				38.33	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
H4982	004	0	1	02	01	H4982_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											876.85	25						712.73	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
H4982	007	0	1	02	01	H4982_007_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	007	0	1	02	01	H4982_007_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	007	0	1	02	01	H4982_007_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.57	24	24	24				115.07	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
H4982	007	0	1	02	01	H4982_007_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.77	25	25	25				38.47	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
H4982	007	0	1	02	01	H4982_007_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											775.00	25						924.72	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
H4982	009	0	1	01	01	H4982_009_0	3		N	Preferred Generic	4	11	1	1	1	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				0.87	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4982	009	0	1	01	01	H4982_009_0	3		N	Generic	4	01	1	1	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				3.13	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4982	009	0	1	01	01	H4982_009_0	3		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				86.22	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
H4982	009	0	1	01	01	H4982_009_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.56	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
H4982	009	0	1	01	01	H4982_009_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				562.55	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H4982	010	0	1	02	01	H4982_010_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	010	0	1	02	01	H4982_010_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	010	0	1	02	01	H4982_010_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.05	24	24	24				110.94	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
H4982	010	0	1	02	01	H4982_010_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.75	25	25	25				40.29	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
H4982	010	0	1	02	01	H4982_010_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											764.51	25						794.75	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
H4982	017	0	1	02	01	H4982_017_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	017	0	1	02	01	H4982_017_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	017	0	1	02	01	H4982_017_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.87	22	22	22				85.59	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.00	25	25	25				36.21	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
H4982	017	0	1	02	01	H4982_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											698.03	27						691.75	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
H4982	018	0	1	02	01	H4982_018_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	018	0	1	02	01	H4982_018_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	018	0	1	02	01	H4982_018_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.84	22	22	22				87.13	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	25	25	25				35.87	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
H4982	018	0	1	02	01	H4982_018_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											706.58	27						701.33	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
H4982	020	0	1	02	01	H4982_020_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	020	0	1	02	01	H4982_020_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4982	020	0	1	02	01	H4982_020_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.12	25	25	25				79.75	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
H4982	020	0	1	02	01	H4982_020_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.26	35	35	35				28.26	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
H4982	020	0	1	02	01	H4982_020_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1011.32	33						946.51	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
H4982	021	0	1	02	01	H4982_021_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	021	0	1	02	01	H4982_021_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	021	0	1	02	01	H4982_021_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.55	22	22	22				83.22	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	021	0	1	02	01	H4982_021_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.69	25	25	25				36.82	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
H4982	021	0	1	02	01	H4982_021_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											690.42	27						678.50	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
H4982	022	0	1	02	01	H4982_022_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	022	0	1	02	01	H4982_022_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	022	0	1	02	01	H4982_022_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.55	22	22	22				83.22	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	022	0	1	02	01	H4982_022_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.69	25	25	25				36.83	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
H4982	022	0	1	02	01	H4982_022_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											690.42	27						678.56	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
H4982	023	0	1	02	01	H4982_023_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	023	0	1	02	01	H4982_023_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4982	023	0	1	02	01	H4982_023_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.71	25	25	25				80.03	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
H4982	023	0	1	02	01	H4982_023_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.57	35	35	35				27.50	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
H4982	023	0	1	02	01	H4982_023_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1051.81	33						972.13	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
H4982	024	0	1	02	01	H4982_024_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	024	0	1	02	01	H4982_024_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	024	0	1	02	01	H4982_024_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.55	22	22	22				83.22	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	024	0	1	02	01	H4982_024_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.69	25	25	25				36.83	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
H4982	024	0	1	02	01	H4982_024_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											690.42	27						678.70	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
H4982	025	0	1	02	01	H4982_025_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	025	0	1	02	01	H4982_025_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4982	025	0	1	02	01	H4982_025_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.12	25	25	25				79.75	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
H4982	025	0	1	02	01	H4982_025_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.26	35	35	35				28.27	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
H4982	025	0	1	02	01	H4982_025_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1011.32	33						947.73	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
H4982	026	0	1	02	01	H4982_026_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	026	0	1	02	01	H4982_026_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4982	026	0	1	02	01	H4982_026_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.12	25	25	25				79.75	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
H4982	026	0	1	02	01	H4982_026_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.26	35	35	35				28.26	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
H4982	026	0	1	02	01	H4982_026_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1011.32	33						945.74	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
H4982	027	0	1	02	01	H4982_027_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	027	0	1	02	01	H4982_027_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H4982	027	0	1	02	01	H4982_027_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.12	25	25	25				79.75	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
H4982	027	0	1	02	01	H4982_027_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.26	35	35	35				28.26	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
H4982	027	0	1	02	01	H4982_027_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1011.32	33						946.59	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
H4982	028	0	1	02	01	H4982_028_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	028	0	1	02	01	H4982_028_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	028	0	1	02	01	H4982_028_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.39	24	24	24				103.42	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
H4982	028	0	1	02	01	H4982_028_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.98	25	25	25				35.12	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
H4982	028	0	1	02	01	H4982_028_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											739.28	25						690.95	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
H4982	029	0	1	02	01	H4982_029_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	029	0	1	02	01	H4982_029_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	029	0	1	02	01	H4982_029_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.39	24	24	24				103.42	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
H4982	029	0	1	02	01	H4982_029_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.98	25	25	25				35.12	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
H4982	029	0	1	02	01	H4982_029_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											739.28	25						690.51	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
H4982	030	0	1	02	01	H4982_030_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	030	0	1	02	01	H4982_030_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H4982	030	0	1	02	01	H4982_030_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.39	24	24	24				103.42	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
H4982	030	0	1	02	01	H4982_030_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.98	25	25	25				35.16	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
H4982	030	0	1	02	01	H4982_030_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											739.28	25						693.64	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
H5009	002	0	1	04	01	H5009_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								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H5009	002	0	1	04	01	H5009_002_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	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				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	26.00	8.00	16.00	16.00	13.00	26.00	26.00	8.00	16.00	16.00	13.00		13.00
H5009	002	0	1	04	01	H5009_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											53.29	25	25	25				53.29	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H5009	002	0	1	04	01	H5009_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											62.40	43	43	43				62.40	40	40	40										43	43	43				40	40	40			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
H5009	002	0	1	04	01	H5009_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											861.63	30						861.63	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5009	011	1	1	04	01	H5009_011_1	5			Preferred Generic	4	01	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										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
H5009	011	1	1	04	01	H5009_011_1	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	39.00					10.00	20.00	30.00											13.00	26.00	39.00				10.00	20.00	0.00				13.00				13.00			0.43	0.33		0.43	0.33	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	39.00	10.00	20.00	30.00	13.00	26.00	39.00	10.00	20.00	0.00	13.00		13.00
H5009	011	1	1	04	01	H5009_011_1	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											46.00	25	25	25				46.00	22	22	22										25	25	25				22	22	22			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
H5009	011	1	1	04	01	H5009_011_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											45.99	43	43	43				45.99	40	40	40										43	43	43				40	40	40			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
H5009	011	1	1	04	01	H5009_011_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											851.86	29						851.86	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5009	011	2	1	04	01	H5009_011_2	5			Preferred Generic	4	01	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										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
H5009	011	2	1	04	01	H5009_011_2	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	39.00					10.00	20.00	30.00											13.00	26.00	39.00				10.00	20.00	0.00				13.00				13.00			0.43	0.33		0.43	0.33	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	39.00	10.00	20.00	30.00	13.00	26.00	39.00	10.00	20.00	0.00	13.00		13.00
H5009	011	2	1	04	01	H5009_011_2	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											46.00	25	25	25				46.00	22	22	22										25	25	25				22	22	22			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
H5009	011	2	1	04	01	H5009_011_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											45.99	43	43	43				45.99	40	40	40										43	43	43				40	40	40			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
H5009	011	2	1	04	01	H5009_011_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											851.86	29						851.86	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5010	011	0	1	04	01	H5010_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								3.00	6.00	6.00					0.00	0.00	0.00											3.00	6.00	6.00				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	6.00	0.00	0.00	0.00	3.00	6.00	6.00	0.00	0.00	0.00	3.00		3.00
H5010	011	0	1	04	01	H5010_011_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								13.00	26.00	26.00					5.00	10.00	10.00											13.00	26.00	26.00				5.00	10.00	10.00				13.00				13.00			0.43	0.17		0.43	0.17	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	26.00	5.00	10.00	10.00	13.00	26.00	26.00	5.00	10.00	10.00	13.00		13.00
H5010	011	0	1	04	01	H5010_011_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											50.11	25	25	25				50.11	22	22	22										25	25	25				22	22	22			25			25								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	70.00	100.00	35.00		35.00
H5010	011	0	1	04	01	H5010_011_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											67.96	43	43	43				67.96	40	40	40										43	43	43				40	40	40			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
H5010	011	0	1	04	01	H5010_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											977.68	30						977.68	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5042	009	0	1	04	01	H5042_009_0	9			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	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					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	0.67	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5042	009	0	1	04	01	H5042_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					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	1.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.06	40	40	40				40.00	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	70.00	35.00		35.00
H5042	009	0	1	04	01	H5042_009_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1399.46	29						1399.46	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5042	014	0	1	04	01	H5042_014_0	9			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	014	0	1	04	01	H5042_014_0	9			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	014	0	1	04	01	H5042_014_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					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	1.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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	014	0	1	04	01	H5042_014_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											81.57	45	45	45				81.57	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	70.00	35.00		35.00
H5042	014	0	1	04	01	H5042_014_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1399.46	33						1399.46	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5050	004	0	1	01	01	H5050_004_0	4			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										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	4			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										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	4			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										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	4			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										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	4			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										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	4			Vaccines	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																								
H5050	009	0	1	01	01	H5050_009_0	4			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										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	4			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										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	4			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										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	4			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										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	4			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										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	4			Vaccines	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																								
H5050	013	0	1	01	01	H5050_013_0	4			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										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	4			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										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	4			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										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	4			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										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	4			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										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	4			Vaccines	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																								
H5050	017	0	1	01	01	H5050_017_0	4			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										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	4			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										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	4			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										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	4			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										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	4			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										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	4			Vaccines	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																								
H5050	019	0	1	01	01	H5050_019_0	4			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										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	4			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										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	4			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										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	4			Non-Preferred Drug	4	11	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										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	4			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										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	4			Vaccines	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																								
H5050	021	0	1	01	01	H5050_021_0	4			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										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	4			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										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	4			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										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	4			Non-Preferred Drug	4	11	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										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	4			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										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	4			Vaccines	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																								
H5050	022	0	1	01	01	H5050_022_0	5			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										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	5			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										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	5			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					40.00	80.00	120.00					40.00	80.00	100.00																40.00				40.00			1.33	1.33	1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	100.00				35.00		35.00
H5050	022	0	1	01	01	H5050_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		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										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	5			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										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	5			Vaccines	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																								
H5050	023	0	1	01	01	H5050_023_0	4			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										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	4			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										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	4			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										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	4			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										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	4			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										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	4			Vaccines	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																								
H5087	005	0	1	01	01	H5087_005_0	5			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	005	0	1	01	01	H5087_005_0	5			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																								
H5087	005	0	1	01	01	H5087_005_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											148.03	25	25	25				148.03	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
H5087	005	0	1	01	01	H5087_005_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											94.18	37	37	37				94.18	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
H5087	005	0	1	01	01	H5087_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, Select Care Drugs																								
H5087	005	0	1	01	01	H5087_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	0.00				0.00				0.00			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	5			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	016	0	1	01	01	H5087_016_0	5			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																								
H5087	016	0	1	01	01	H5087_016_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.72	25	25	25				159.72	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
H5087	016	0	1	01	01	H5087_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											65.94	33	33	33				63.94	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	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, Select Care Drugs																								
H5087	016	0	1	01	01	H5087_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																								
H5087	024	0	1	01	01	H5087_024_0	5			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	5			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																								
H5087	024	0	1	01	01	H5087_024_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											152.04	25	25	25				152.04	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
H5087	024	0	1	01	01	H5087_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											80.47	50	50	50				80.47	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
H5087	024	0	1	01	01	H5087_024_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, Select Care Drugs																								
H5087	024	0	1	01	01	H5087_024_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																								
H5087	032	0	1	01	01	H5087_032_0	5			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	032	0	1	01	01	H5087_032_0	5			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																								
H5087	032	0	1	01	01	H5087_032_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.85	25	25	25				156.85	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
H5087	032	0	1	01	01	H5087_032_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											97.09	37	37	37				94.47	36	36	36										37	37	37				36	36	36			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
H5087	032	0	1	01	01	H5087_032_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, Select Care Drugs																								
H5087	032	0	1	01	01	H5087_032_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																								
H5106	013	0	1	04	01	H5106_013_0	6			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	6			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	6			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	6			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	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	029	1	1	04	01	H5106_029_1	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											106.01	25		25				105.50	25		25												25						25			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
H5106	029	1	1	04	01	H5106_029_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.49	50		50				34.81	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
H5106	029	1	1	04	01	H5106_029_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	029	2	1	04	01	H5106_029_2	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											106.01	25		25				105.50	25		25												25						25			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
H5106	029	2	1	04	01	H5106_029_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.49	50		50				34.81	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
H5106	029	2	1	04	01	H5106_029_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	030	1	1	04	01	H5106_030_1	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											103.52	25		25				108.47	25		25												25						25			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
H5106	030	1	1	04	01	H5106_030_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.59	46		46				30.63	46		46												46						46			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
H5106	030	1	1	04	01	H5106_030_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	030	2	1	04	01	H5106_030_2	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											103.52	25		25				108.47	25		25												25						25			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
H5106	030	2	1	04	01	H5106_030_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.59	46		46				30.63	46		46												46						46			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
H5106	030	2	1	04	01	H5106_030_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	031	1	1	04	01	H5106_031_1	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											96.04	21		21				95.74	21		21												21						21			21			21								Preferred Generic, 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	031	1	1	04	01	H5106_031_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											31.98	21		21				22.04	21		21												21						21			21			21								Preferred Generic, 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	031	1	1	04	01	H5106_031_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	031	2	1	04	01	H5106_031_2	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											96.04	21		21				95.74	21		21												21						21			21			21								Preferred Generic, 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	031	2	1	04	01	H5106_031_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											31.98	21		21				22.04	21		21												21						21			21			21								Preferred Generic, 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	031	2	1	04	01	H5106_031_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	032	1	1	04	01	H5106_032_1	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											102.96	25		25				101.78	25		25												25						25			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
H5106	032	1	1	04	01	H5106_032_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.80	50		50				34.73	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
H5106	032	1	1	04	01	H5106_032_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5106	032	2	1	04	01	H5106_032_2	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											102.96	25		25				101.78	25		25												25						25			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
H5106	032	2	1	04	01	H5106_032_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.80	50		50				34.73	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
H5106	032	2	1	04	01	H5106_032_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5141	004	0	1	04	01	H5141_004_0	6			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	6			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				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																								
H5141	004	0	1	04	01	H5141_004_0	6			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																					135.00																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	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										35.00	70.00	105.00						105.00				35.00		35.00
H5141	004	0	1	04	01	H5141_004_0	6			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					31	31	31																				31															31			31								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	6			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	6			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				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																								
H5141	007	0	1	04	01	H5141_007_0	6			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																					135.00																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	007	0	1	04	01	H5141_007_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				83.68	35	35	35																				35															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	007	0	1	04	01	H5141_007_0	6			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	025	0	1	04	01	H5141_025_0	6			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	6			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	6			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																					135.00																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	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										35.00	70.00	105.00						105.00				35.00		35.00
H5141	025	0	1	04	01	H5141_025_0	6			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	6			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	6			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	6			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																					135.00																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	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										35.00	70.00	105.00						105.00				35.00		35.00
H5141	026	0	1	04	01	H5141_026_0	6			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	6			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	6			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	6			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																					135.00																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	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										35.00	70.00	105.00						105.00				35.00		35.00
H5141	032	0	1	04	01	H5141_032_0	6			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	6			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	6			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	6			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																					135.00																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	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										35.00	70.00	105.00						105.00				35.00		35.00
H5141	036	0	1	04	01	H5141_036_0	6			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	6			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	6			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	6			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																					135.00																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	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										35.00	70.00	105.00						105.00				35.00		35.00
H5141	038	0	1	04	01	H5141_038_0	6			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	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																								
H5141	042	0	1	04	01	H5141_042_0	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				49.99	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	042	0	1	04	01	H5141_042_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				73.18	35	35	35																				35															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	7			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					31	31	31																				31															31			31								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	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				58.99	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	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				82.62	35	35	35																				35															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	045	0	1	04	01	H5141_045_0	6			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	054	0	1	04	01	H5141_054_0	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				66.26	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
H5141	054	0	1	04	01	H5141_054_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				85.46	34	34	34																				34															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	054	0	1	04	01	H5141_054_0	6			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
H5163	001	0	1	01	01	H5163_001_0	7			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 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	7			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 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	7			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	7			Non-Preferred Brand	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				91.88	30	30	30																		30	30	20															30			30								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
H5163	001	0	1	01	01	H5163_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				641.61	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	7			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 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	7			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 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	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	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 Brand, Specialty Tier, Select Care Drugs										30.00	60.00	90.00				30.00	60.00	60.00				30.00		30.00
H5163	002	0	1	01	01	H5163_002_0	7			Non-Preferred Brand	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				70.72	28	28	28																		28	28	19															28			28								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
H5163	002	0	1	01	01	H5163_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				782.83	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
H5163	002	0	1	01	01	H5163_002_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	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
H5178	002	0	1	01	01	H5178_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
H5178	002	0	1	01	01	H5178_002_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
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		95.00	35.00		35.00
H5178	002	0	1	01	01	H5178_002_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				76.00	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
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
H5211	002	0	1	02	01	H5211_002_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	34	68	102				1	2	34	68	102				34		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
H5211	002	0	1	02	01	H5211_002_0	6			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, Select Care Drugs										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	6			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, Select Care Drugs										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	6			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, Select Care Drugs										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	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5211	002	0	1	02	01	H5211_002_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	34	68	102				1	2	34	68	102				34		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																								
H5211	004	0	1	02	01	H5211_004_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	34	68	102				1	2	34	68	102				34		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
H5211	004	0	1	02	01	H5211_004_0	6			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, Select Care Drugs										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	6			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, Select Care Drugs										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	6			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, Select Care Drugs										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	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5211	004	0	1	02	01	H5211_004_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	34	68	102				1	2	34	68	102				34		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																								
H5211	012	0	1	02	01	H5211_012_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	34	68	102				1	2	34	68	102				34		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
H5211	012	0	1	02	01	H5211_012_0	11			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, Select Care Drugs										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	11			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, Select Care Drugs										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	11			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, Select Care Drugs										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	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5211	012	0	1	02	01	H5211_012_0	11			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	34	68	102				1	2	34	68	102				34		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																								
H5215	002	0	1	04	01	H5215_002_0	23			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	23			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	23			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											79.22	24		24				84.72	23		23										24		24				23		23			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
H5215	002	0	1	04	01	H5215_002_0	23			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											98.03	46		46				75.68	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
H5215	002	0	1	04	01	H5215_002_0	23			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																								
H5215	005	0	1	04	01	H5215_005_0	9			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	9			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	9			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											71.76	22		22				72.40	21		21										22		22				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		105.00	35.00		35.00
H5215	005	0	1	04	01	H5215_005_0	9			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											94.18	45		45				93.57	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
H5215	005	0	1	04	01	H5215_005_0	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																								
H5215	008	0	1	04	01	H5215_008_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	008	0	1	04	01	H5215_008_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	008	0	1	04	01	H5215_008_0	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											87.86	25		25				92.17	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		105.00	35.00		35.00
H5215	008	0	1	04	01	H5215_008_0	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											95.62	50		50				85.03	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
H5215	008	0	1	04	01	H5215_008_0	8			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	009	0	1	04	01	H5215_009_0	10			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	10			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	10			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											79.70	25		25				80.13	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		105.00	35.00		35.00
H5215	009	0	1	04	01	H5215_009_0	10			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											99.48	37		37				79.18	37		37										37		37				37		37			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		105.00	35.00		35.00
H5215	009	0	1	04	01	H5215_009_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																								
H5215	010	0	1	04	01	H5215_010_0	11			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	11			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	11			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											79.02	24		24				73.69	23		23										24		24				23		23			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
H5215	010	0	1	04	01	H5215_010_0	11			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											99.98	37		37				78.52	37		37										37		37				37		37			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		105.00	35.00		35.00
H5215	010	0	1	04	01	H5215_010_0	11			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	11			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	11			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	11			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											80.83	24		24				86.55	23		23										24		24				23		23			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
H5215	011	0	1	04	01	H5215_011_0	11			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											98.87	49		49				88.87	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
H5215	011	0	1	04	01	H5215_011_0	11			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	9			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	9			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	9			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	9			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											99.14	41		41				65.14	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
H5215	012	0	1	04	01	H5215_012_0	9			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																								
H5216	001	0	1	04	01	H5216_001_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
H5216	001	0	1	04	01	H5216_001_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
H5216	001	0	1	04	01	H5216_001_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		95.00	35.00		35.00
H5216	001	0	1	04	01	H5216_001_0	4			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																								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	001	0	1	04	01	H5216_001_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
H5216	006	0	1	04	01	H5216_006_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
H5216	006	0	1	04	01	H5216_006_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
H5216	006	0	1	04	01	H5216_006_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		95.00	35.00		35.00
H5216	006	0	1	04	01	H5216_006_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				76.00	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	006	0	1	04	01	H5216_006_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
H5216	011	0	1	04	01	H5216_011_0	3			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	3			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	3			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		95.00	35.00		35.00
H5216	011	0	1	04	01	H5216_011_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	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	011	0	1	04	01	H5216_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 Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5216	013	0	1	04	01	H5216_013_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
H5216	013	0	1	04	01	H5216_013_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
H5216	013	0	1	04	01	H5216_013_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		95.00	35.00		35.00
H5216	013	0	1	04	01	H5216_013_0	4			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																								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	013	0	1	04	01	H5216_013_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
H5216	014	0	1	04	01	H5216_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
H5216	014	0	1	04	01	H5216_014_0	4			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	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		95.00	35.00		35.00
H5216	014	0	1	04	01	H5216_014_0	4			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																								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	014	0	1	04	01	H5216_014_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
H5216	017	0	1	04	01	H5216_017_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
H5216	017	0	1	04	01	H5216_017_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
H5216	017	0	1	04	01	H5216_017_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		95.00	35.00		35.00
H5216	017	0	1	04	01	H5216_017_0	4			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																								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	017	0	1	04	01	H5216_017_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
H5216	019	0	1	04	01	H5216_019_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
H5216	019	0	1	04	01	H5216_019_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
H5216	019	0	1	04	01	H5216_019_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		95.00	35.00		35.00
H5216	019	0	1	04	01	H5216_019_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				87.00	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	019	0	1	04	01	H5216_019_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
H5216	023	0	1	04	01	H5216_023_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
H5216	023	0	1	04	01	H5216_023_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
H5216	023	0	1	04	01	H5216_023_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		95.00	35.00		35.00
H5216	023	0	1	04	01	H5216_023_0	4			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																								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	023	0	1	04	01	H5216_023_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
H5216	024	0	1	04	01	H5216_024_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
H5216	024	0	1	04	01	H5216_024_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
H5216	024	0	1	04	01	H5216_024_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		95.00	35.00		35.00
H5216	024	0	1	04	01	H5216_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	024	0	1	04	01	H5216_024_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
H5216	027	0	1	04	01	H5216_027_0	4			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	4			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	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		95.00	35.00		35.00
H5216	027	0	1	04	01	H5216_027_0	4			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																								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	027	0	1	04	01	H5216_027_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
H5216	032	0	1	04	01	H5216_032_0	4			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	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
H5216	032	0	1	04	01	H5216_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		95.00	35.00		35.00
H5216	032	0	1	04	01	H5216_032_0	4			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																								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	032	0	1	04	01	H5216_032_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
H5216	034	0	1	04	01	H5216_034_0	4			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
H5216	034	0	1	04	01	H5216_034_0	4			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
H5216	034	0	1	04	01	H5216_034_0	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		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		70.00	35.00		35.00
H5216	034	0	1	04	01	H5216_034_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	034	0	1	04	01	H5216_034_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
H5216	037	0	1	04	01	H5216_037_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
H5216	037	0	1	04	01	H5216_037_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
H5216	037	0	1	04	01	H5216_037_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		95.00	35.00		35.00
H5216	037	0	1	04	01	H5216_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	037	0	1	04	01	H5216_037_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
H5216	039	0	1	04	01	H5216_039_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
H5216	039	0	1	04	01	H5216_039_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
H5216	039	0	1	04	01	H5216_039_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		95.00	35.00		35.00
H5216	039	0	1	04	01	H5216_039_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	039	0	1	04	01	H5216_039_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
H5216	042	0	1	04	01	H5216_042_0	4			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	4			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	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		95.00	35.00		35.00
H5216	042	0	1	04	01	H5216_042_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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		35.00
H5216	042	0	1	04	01	H5216_042_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
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			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	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		95.00	35.00		35.00
H5216	043	1	1	04	01	H5216_043_1	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		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					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	5	1	04	01	H5216_043_5	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
H5216	043	5	1	04	01	H5216_043_5	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	043	5	1	04	01	H5216_043_5	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		95.00	35.00		35.00
H5216	043	5	1	04	01	H5216_043_5	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H5216	043	5	1	04	01	H5216_043_5	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
H5216	043	6	1	04	01	H5216_043_6	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
H5216	043	6	1	04	01	H5216_043_6	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	043	6	1	04	01	H5216_043_6	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		95.00	35.00		35.00
H5216	043	6	1	04	01	H5216_043_6	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H5216	043	6	1	04	01	H5216_043_6	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
H5216	047	0	1	04	01	H5216_047_0	3			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	3			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	047	0	1	04	01	H5216_047_0	3			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		95.00	35.00		35.00
H5216	047	0	1	04	01	H5216_047_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				87.00	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	047	0	1	04	01	H5216_047_0	3			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	048	0	1	04	01	H5216_048_0	3			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				1.00	24		24																								24		24				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H5216	048	0	1	04	01	H5216_048_0	3			Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H5216	048	0	1	04	01	H5216_048_0	3			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	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	048	0	1	04	01	H5216_048_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				57.00	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	048	0	1	04	01	H5216_048_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										35.00						35.00			35.00			35.00		35.00
H5216	053	0	1	04	01	H5216_053_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
H5216	053	0	1	04	01	H5216_053_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
H5216	053	0	1	04	01	H5216_053_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		95.00	35.00		35.00
H5216	053	0	1	04	01	H5216_053_0	4			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																								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	053	0	1	04	01	H5216_053_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
H5216	062	0	1	04	01	H5216_062_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
H5216	062	0	1	04	01	H5216_062_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
H5216	062	0	1	04	01	H5216_062_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	062	0	1	04	01	H5216_062_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
H5216	063	0	1	04	01	H5216_063_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
H5216	063	0	1	04	01	H5216_063_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
H5216	063	0	1	04	01	H5216_063_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		95.00	35.00		35.00
H5216	063	0	1	04	01	H5216_063_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				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		35.00
H5216	063	0	1	04	01	H5216_063_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
H5216	064	0	1	04	01	H5216_064_0	4			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
H5216	064	0	1	04	01	H5216_064_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
H5216	064	0	1	04	01	H5216_064_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		95.00	35.00		35.00
H5216	064	0	1	04	01	H5216_064_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	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	064	0	1	04	01	H5216_064_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
H5216	068	0	1	04	01	H5216_068_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
H5216	068	0	1	04	01	H5216_068_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
H5216	068	0	1	04	01	H5216_068_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		95.00	35.00		35.00
H5216	068	0	1	04	01	H5216_068_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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
H5216	068	0	1	04	01	H5216_068_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
H5216	070	0	1	04	01	H5216_070_0	4			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
H5216	070	0	1	04	01	H5216_070_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
H5216	070	0	1	04	01	H5216_070_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		95.00	35.00		35.00
H5216	070	0	1	04	01	H5216_070_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	070	0	1	04	01	H5216_070_0	4			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	072	0	1	04	01	H5216_072_0	4			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
H5216	072	0	1	04	01	H5216_072_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
H5216	072	0	1	04	01	H5216_072_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		95.00	35.00		35.00
H5216	072	0	1	04	01	H5216_072_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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		35.00
H5216	072	0	1	04	01	H5216_072_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
H5216	073	0	1	04	01	H5216_073_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
H5216	073	0	1	04	01	H5216_073_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
H5216	073	0	1	04	01	H5216_073_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		95.00	35.00		35.00
H5216	073	0	1	04	01	H5216_073_0	4			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	073	0	1	04	01	H5216_073_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
H5216	074	0	1	04	01	H5216_074_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
H5216	074	0	1	04	01	H5216_074_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
H5216	074	0	1	04	01	H5216_074_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		95.00	35.00		35.00
H5216	074	0	1	04	01	H5216_074_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				89.00	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	074	0	1	04	01	H5216_074_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
H5216	078	1	1	04	01	H5216_078_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	078	1	1	04	01	H5216_078_1	4			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
H5216	078	1	1	04	01	H5216_078_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		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		70.00	35.00		35.00
H5216	078	1	1	04	01	H5216_078_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	078	1	1	04	01	H5216_078_1	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
H5216	078	2	1	04	01	H5216_078_2	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	078	2	1	04	01	H5216_078_2	4			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
H5216	078	2	1	04	01	H5216_078_2	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		70.00	35.00		35.00
H5216	078	2	1	04	01	H5216_078_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	078	2	1	04	01	H5216_078_2	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
H5216	078	6	1	04	01	H5216_078_6	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	078	6	1	04	01	H5216_078_6	4			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
H5216	078	6	1	04	01	H5216_078_6	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		70.00	35.00		35.00
H5216	078	6	1	04	01	H5216_078_6	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	078	6	1	04	01	H5216_078_6	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
H5216	081	0	1	04	01	H5216_081_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	081	0	1	04	01	H5216_081_0	3			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																								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	081	0	1	04	01	H5216_081_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										35.00						35.00			35.00			35.00		35.00
H5216	083	0	1	04	01	H5216_083_0	4			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	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
H5216	083	0	1	04	01	H5216_083_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		95.00	35.00		35.00
H5216	083	0	1	04	01	H5216_083_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				72.00	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	083	0	1	04	01	H5216_083_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
H5216	088	0	1	04	01	H5216_088_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
H5216	088	0	1	04	01	H5216_088_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
H5216	088	0	1	04	01	H5216_088_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		95.00	35.00		35.00
H5216	088	0	1	04	01	H5216_088_0	4			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																								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	088	0	1	04	01	H5216_088_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
H5216	089	0	1	04	01	H5216_089_0	3			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	3			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	089	0	1	04	01	H5216_089_0	3			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		95.00	35.00		35.00
H5216	089	0	1	04	01	H5216_089_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				89.00	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	089	0	1	04	01	H5216_089_0	3			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	092	0	1	04	01	H5216_092_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	092	0	1	04	01	H5216_092_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				87.00	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	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										35.00						35.00			35.00			35.00		35.00
H5216	097	0	1	04	01	H5216_097_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
H5216	097	0	1	04	01	H5216_097_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
H5216	097	0	1	04	01	H5216_097_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		95.00	35.00		35.00
H5216	097	0	1	04	01	H5216_097_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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	097	0	1	04	01	H5216_097_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
H5216	100	0	1	04	01	H5216_100_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	100	0	1	04	01	H5216_100_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	100	0	1	04	01	H5216_100_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		95.00	35.00		35.00
H5216	100	0	1	04	01	H5216_100_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	100	0	1	04	01	H5216_100_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	106	0	1	04	01	H5216_106_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
H5216	106	0	1	04	01	H5216_106_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
H5216	106	0	1	04	01	H5216_106_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		95.00	35.00		35.00
H5216	106	0	1	04	01	H5216_106_0	4			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																								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	106	0	1	04	01	H5216_106_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
H5216	107	0	1	04	01	H5216_107_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
H5216	107	0	1	04	01	H5216_107_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
H5216	107	0	1	04	01	H5216_107_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		95.00	35.00		35.00
H5216	107	0	1	04	01	H5216_107_0	4			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																								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	107	0	1	04	01	H5216_107_0	4			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	114	0	1	04	01	H5216_114_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
H5216	114	0	1	04	01	H5216_114_0	4			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	114	0	1	04	01	H5216_114_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		95.00	35.00		35.00
H5216	114	0	1	04	01	H5216_114_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	114	0	1	04	01	H5216_114_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
H5216	117	0	1	04	01	H5216_117_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
H5216	117	0	1	04	01	H5216_117_0	4			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	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		95.00	35.00		35.00
H5216	117	0	1	04	01	H5216_117_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				85.00	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		35.00
H5216	117	0	1	04	01	H5216_117_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
H5216	120	0	1	04	01	H5216_120_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
H5216	120	0	1	04	01	H5216_120_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
H5216	120	0	1	04	01	H5216_120_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		95.00	35.00		35.00
H5216	120	0	1	04	01	H5216_120_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	120	0	1	04	01	H5216_120_0	4			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	124	0	1	04	01	H5216_124_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
H5216	124	0	1	04	01	H5216_124_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
H5216	124	0	1	04	01	H5216_124_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		95.00	35.00		35.00
H5216	124	0	1	04	01	H5216_124_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				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		35.00
H5216	124	0	1	04	01	H5216_124_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
H5216	131	0	1	04	01	H5216_131_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
H5216	131	0	1	04	01	H5216_131_0	4			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	131	0	1	04	01	H5216_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		95.00	35.00		35.00
H5216	131	0	1	04	01	H5216_131_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	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	131	0	1	04	01	H5216_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
H5216	132	0	1	04	01	H5216_132_0	3			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	3			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	132	0	1	04	01	H5216_132_0	3			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		95.00	35.00		35.00
H5216	132	0	1	04	01	H5216_132_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	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		35.00
H5216	132	0	1	04	01	H5216_132_0	3			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	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
H5216	133	0	1	04	01	H5216_133_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
H5216	133	0	1	04	01	H5216_133_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		95.00	35.00		35.00
H5216	133	0	1	04	01	H5216_133_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	133	0	1	04	01	H5216_133_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
H5216	136	0	1	04	01	H5216_136_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
H5216	136	0	1	04	01	H5216_136_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
H5216	136	0	1	04	01	H5216_136_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		95.00	35.00		35.00
H5216	136	0	1	04	01	H5216_136_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	136	0	1	04	01	H5216_136_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
H5216	138	0	1	04	01	H5216_138_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
H5216	138	0	1	04	01	H5216_138_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
H5216	138	0	1	04	01	H5216_138_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		95.00	35.00		35.00
H5216	138	0	1	04	01	H5216_138_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				86.00	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	138	0	1	04	01	H5216_138_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
H5216	141	0	1	04	01	H5216_141_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
H5216	141	0	1	04	01	H5216_141_0	4			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	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		95.00	35.00		35.00
H5216	141	0	1	04	01	H5216_141_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		105.00	35.00		35.00
H5216	141	0	1	04	01	H5216_141_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
H5216	142	1	1	04	01	H5216_142_1	4			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	4			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	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		95.00	35.00		35.00
H5216	142	1	1	04	01	H5216_142_1	4			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																								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	142	1	1	04	01	H5216_142_1	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
H5216	142	2	1	04	01	H5216_142_2	4			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	4			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	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		95.00	35.00		35.00
H5216	142	2	1	04	01	H5216_142_2	4			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																								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	142	2	1	04	01	H5216_142_2	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
H5216	144	0	1	04	01	H5216_144_0	4			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	4			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	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		95.00	35.00		35.00
H5216	144	0	1	04	01	H5216_144_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				84.00	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	144	0	1	04	01	H5216_144_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
H5216	154	0	1	04	01	H5216_154_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
H5216	154	0	1	04	01	H5216_154_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
H5216	154	0	1	04	01	H5216_154_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		95.00	35.00		35.00
H5216	154	0	1	04	01	H5216_154_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				94.00	36		36																								36		36				36		36			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
H5216	154	0	1	04	01	H5216_154_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
H5216	168	0	1	04	01	H5216_168_0	4			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	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
H5216	168	0	1	04	01	H5216_168_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		95.00	35.00		35.00
H5216	168	0	1	04	01	H5216_168_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				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		35.00
H5216	168	0	1	04	01	H5216_168_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
H5216	175	0	1	04	01	H5216_175_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
H5216	175	0	1	04	01	H5216_175_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
H5216	175	0	1	04	01	H5216_175_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		95.00	35.00		35.00
H5216	175	0	1	04	01	H5216_175_0	4			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																								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	175	0	1	04	01	H5216_175_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
H5216	176	0	1	04	01	H5216_176_0	4			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		90				1	2				30		90	30		31				1.00	24		24																								24		24				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H5216	176	0	1	04	01	H5216_176_0	4			Generic	4	11	1	1	2	1	110		01		110	1	30		90				2	2				30		90	30		31				3.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H5216	176	0	1	04	01	H5216_176_0	4			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				50.00	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	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				57.00	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	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
H5216	177	0	1	04	01	H5216_177_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
H5216	177	0	1	04	01	H5216_177_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
H5216	177	0	1	04	01	H5216_177_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		95.00	35.00		35.00
H5216	177	0	1	04	01	H5216_177_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	177	0	1	04	01	H5216_177_0	4			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	182	0	1	04	01	H5216_182_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
H5216	182	0	1	04	01	H5216_182_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
H5216	182	0	1	04	01	H5216_182_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		95.00	35.00		35.00
H5216	182	0	1	04	01	H5216_182_0	4			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																								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	182	0	1	04	01	H5216_182_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
H5216	188	0	1	04	01	H5216_188_0	3			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	188	0	1	04	01	H5216_188_0	3			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	188	0	1	04	01	H5216_188_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	188	0	1	04	01	H5216_188_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				84.00	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	188	0	1	04	01	H5216_188_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										35.00						35.00			35.00			35.00		35.00
H5216	192	0	1	04	01	H5216_192_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
H5216	192	0	1	04	01	H5216_192_0	4			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	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		95.00	35.00		35.00
H5216	192	0	1	04	01	H5216_192_0	4			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																								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		35.00
H5216	192	0	1	04	01	H5216_192_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
H5216	193	0	1	04	01	H5216_193_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	193	0	1	04	01	H5216_193_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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		35.00
H5216	193	0	1	04	01	H5216_193_0	3			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	194	0	1	04	01	H5216_194_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
H5216	194	0	1	04	01	H5216_194_0	4			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	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		95.00	35.00		35.00
H5216	194	0	1	04	01	H5216_194_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	194	0	1	04	01	H5216_194_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
H5216	196	1	1	04	01	H5216_196_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	196	1	1	04	01	H5216_196_1	4			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
H5216	196	1	1	04	01	H5216_196_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		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		70.00	35.00		35.00
H5216	196	1	1	04	01	H5216_196_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	196	1	1	04	01	H5216_196_1	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
H5216	196	2	1	04	01	H5216_196_2	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	196	2	1	04	01	H5216_196_2	4			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
H5216	196	2	1	04	01	H5216_196_2	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		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		70.00	35.00		35.00
H5216	196	2	1	04	01	H5216_196_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	196	2	1	04	01	H5216_196_2	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
H5216	203	1	1	04	01	H5216_203_1	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
H5216	203	1	1	04	01	H5216_203_1	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
H5216	203	1	1	04	01	H5216_203_1	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		95.00	35.00		35.00
H5216	203	1	1	04	01	H5216_203_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	39		39																								39		39				39		39			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
H5216	203	1	1	04	01	H5216_203_1	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
H5216	203	2	1	04	01	H5216_203_2	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
H5216	203	2	1	04	01	H5216_203_2	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
H5216	203	2	1	04	01	H5216_203_2	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		95.00	35.00		35.00
H5216	203	2	1	04	01	H5216_203_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	39		39																								39		39				39		39			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
H5216	203	2	1	04	01	H5216_203_2	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
H5216	207	0	1	04	01	H5216_207_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
H5216	207	0	1	04	01	H5216_207_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
H5216	207	0	1	04	01	H5216_207_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		95.00	35.00		35.00
H5216	207	0	1	04	01	H5216_207_0	4			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																								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		35.00
H5216	207	0	1	04	01	H5216_207_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
H5216	211	0	1	04	01	H5216_211_0	4			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	4			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	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		95.00	35.00		35.00
H5216	211	0	1	04	01	H5216_211_0	4			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																								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	211	0	1	04	01	H5216_211_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
H5216	223	0	1	04	01	H5216_223_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
H5216	223	0	1	04	01	H5216_223_0	4			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
H5216	223	0	1	04	01	H5216_223_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		70.00	35.00		35.00
H5216	223	0	1	04	01	H5216_223_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H5216	223	0	1	04	01	H5216_223_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
H5216	224	0	1	04	01	H5216_224_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
H5216	224	0	1	04	01	H5216_224_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
H5216	224	0	1	04	01	H5216_224_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		70.00	35.00		35.00
H5216	224	0	1	04	01	H5216_224_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H5216	224	0	1	04	01	H5216_224_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
H5216	226	0	1	04	01	H5216_226_0	3			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	226	0	1	04	01	H5216_226_0	3			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	226	0	1	04	01	H5216_226_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	226	0	1	04	01	H5216_226_0	3			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																								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	226	0	1	04	01	H5216_226_0	3			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	229	0	1	04	01	H5216_229_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
H5216	229	0	1	04	01	H5216_229_0	4			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	229	0	1	04	01	H5216_229_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		95.00	35.00		35.00
H5216	229	0	1	04	01	H5216_229_0	4			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																								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	229	0	1	04	01	H5216_229_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
H5216	231	0	1	04	01	H5216_231_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
H5216	231	0	1	04	01	H5216_231_0	4			Generic	4	11	1	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	231	0	1	04	01	H5216_231_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		95.00	35.00		35.00
H5216	231	0	1	04	01	H5216_231_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	231	0	1	04	01	H5216_231_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
H5216	232	1	1	04	01	H5216_232_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
H5216	232	1	1	04	01	H5216_232_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
H5216	232	1	1	04	01	H5216_232_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	232	1	1	04	01	H5216_232_1	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	28		28																								28		28				28		28			28			28								Preferred Generic, Generic, 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	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	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	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	232	2	1	04	01	H5216_232_2	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	28		28																								28		28				28		28			28			28								Preferred Generic, Generic, 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					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	233	1	1	04	01	H5216_233_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
H5216	233	1	1	04	01	H5216_233_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
H5216	233	1	1	04	01	H5216_233_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	233	1	1	04	01	H5216_233_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		70.00	35.00		35.00
H5216	233	1	1	04	01	H5216_233_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	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	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
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		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		70.00	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					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	242	0	1	04	01	H5216_242_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	242	0	1	04	01	H5216_242_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
H5216	242	0	1	04	01	H5216_242_0	7			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				35.00	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	242	0	1	04	01	H5216_242_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				34.00	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	242	0	1	04	01	H5216_242_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
H5216	243	0	1	04	01	H5216_243_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	243	0	1	04	01	H5216_243_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																									20.00		60.00				0.00		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	243	0	1	04	01	H5216_243_0	9			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				35.00	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	243	0	1	04	01	H5216_243_0	9			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				34.00	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	243	0	1	04	01	H5216_243_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										35.00						35.00			35.00			35.00		35.00
H5216	244	0	1	04	01	H5216_244_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
H5216	244	0	1	04	01	H5216_244_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
H5216	244	0	1	04	01	H5216_244_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		95.00	35.00		35.00
H5216	244	0	1	04	01	H5216_244_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H5216	244	0	1	04	01	H5216_244_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
H5216	246	0	1	04	01	H5216_246_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
H5216	246	0	1	04	01	H5216_246_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
H5216	246	0	1	04	01	H5216_246_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		95.00	35.00		35.00
H5216	246	0	1	04	01	H5216_246_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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		35.00
H5216	246	0	1	04	01	H5216_246_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
H5216	249	0	1	04	01	H5216_249_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
H5216	249	0	1	04	01	H5216_249_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
H5216	249	0	1	04	01	H5216_249_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		95.00	35.00		35.00
H5216	249	0	1	04	01	H5216_249_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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	249	0	1	04	01	H5216_249_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
H5216	250	0	1	04	01	H5216_250_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
H5216	250	0	1	04	01	H5216_250_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
H5216	250	0	1	04	01	H5216_250_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		95.00	35.00		35.00
H5216	250	0	1	04	01	H5216_250_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	250	0	1	04	01	H5216_250_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
H5216	251	0	1	04	01	H5216_251_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
H5216	251	0	1	04	01	H5216_251_0	4			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	251	0	1	04	01	H5216_251_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		95.00	35.00		35.00
H5216	251	0	1	04	01	H5216_251_0	4			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																								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		35.00
H5216	251	0	1	04	01	H5216_251_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
H5216	252	0	1	04	01	H5216_252_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
H5216	252	0	1	04	01	H5216_252_0	4			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	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		95.00	35.00		35.00
H5216	252	0	1	04	01	H5216_252_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H5216	252	0	1	04	01	H5216_252_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
H5216	253	0	1	04	01	H5216_253_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
H5216	253	0	1	04	01	H5216_253_0	4			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	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		95.00	35.00		35.00
H5216	253	0	1	04	01	H5216_253_0	4			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																								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	253	0	1	04	01	H5216_253_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
H5216	255	0	1	04	01	H5216_255_0	3			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	3			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	255	0	1	04	01	H5216_255_0	3			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		95.00	35.00		35.00
H5216	255	0	1	04	01	H5216_255_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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	255	0	1	04	01	H5216_255_0	3			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	261	0	1	04	01	H5216_261_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
H5216	261	0	1	04	01	H5216_261_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
H5216	261	0	1	04	01	H5216_261_0	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		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		70.00	35.00		35.00
H5216	261	0	1	04	01	H5216_261_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	261	0	1	04	01	H5216_261_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
H5216	263	0	1	04	01	H5216_263_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
H5216	263	0	1	04	01	H5216_263_0	4			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
H5216	263	0	1	04	01	H5216_263_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		70.00	35.00		35.00
H5216	263	0	1	04	01	H5216_263_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H5216	263	0	1	04	01	H5216_263_0	4			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	264	0	1	04	01	H5216_264_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	264	0	1	04	01	H5216_264_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	264	0	1	04	01	H5216_264_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		95.00	35.00		35.00
H5216	264	0	1	04	01	H5216_264_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				87.00	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		35.00
H5216	264	0	1	04	01	H5216_264_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	265	0	1	04	01	H5216_265_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
H5216	265	0	1	04	01	H5216_265_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
H5216	265	0	1	04	01	H5216_265_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		70.00	35.00		35.00
H5216	265	0	1	04	01	H5216_265_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H5216	265	0	1	04	01	H5216_265_0	4			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	266	0	1	04	01	H5216_266_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
H5216	266	0	1	04	01	H5216_266_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
H5216	266	0	1	04	01	H5216_266_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		95.00	35.00		35.00
H5216	266	0	1	04	01	H5216_266_0	4			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																								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		35.00
H5216	266	0	1	04	01	H5216_266_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
H5216	269	0	1	04	01	H5216_269_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
H5216	269	0	1	04	01	H5216_269_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
H5216	269	0	1	04	01	H5216_269_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		95.00	35.00		35.00
H5216	269	0	1	04	01	H5216_269_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	269	0	1	04	01	H5216_269_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
H5216	271	0	1	04	01	H5216_271_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	271	0	1	04	01	H5216_271_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
H5216	271	0	1	04	01	H5216_271_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		95.00	35.00		35.00
H5216	271	0	1	04	01	H5216_271_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				90.00	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	271	0	1	04	01	H5216_271_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	275	0	1	04	01	H5216_275_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
H5216	275	0	1	04	01	H5216_275_0	4			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	275	0	1	04	01	H5216_275_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		95.00	35.00		35.00
H5216	275	0	1	04	01	H5216_275_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				90.00	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	275	0	1	04	01	H5216_275_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
H5216	280	1	1	04	01	H5216_280_1	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																									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	4			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	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		95.00	35.00		35.00
H5216	280	1	1	04	01	H5216_280_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				93.00	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
H5216	280	1	1	04	01	H5216_280_1	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
H5216	280	2	1	04	01	H5216_280_2	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																									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	4			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	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		95.00	35.00		35.00
H5216	280	2	1	04	01	H5216_280_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				93.00	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
H5216	280	2	1	04	01	H5216_280_2	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
H5216	281	0	1	04	01	H5216_281_0	3			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	3			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	281	0	1	04	01	H5216_281_0	3			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		95.00	35.00		35.00
H5216	281	0	1	04	01	H5216_281_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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	281	0	1	04	01	H5216_281_0	3			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	283	0	1	04	01	H5216_283_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
H5216	283	0	1	04	01	H5216_283_0	4			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	283	0	1	04	01	H5216_283_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		95.00	35.00		35.00
H5216	283	0	1	04	01	H5216_283_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		35.00
H5216	283	0	1	04	01	H5216_283_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
H5216	284	0	1	04	01	H5216_284_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																									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	4			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	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		95.00	35.00		35.00
H5216	284	0	1	04	01	H5216_284_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	36		36																								36		36				36		36			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
H5216	284	0	1	04	01	H5216_284_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
H5216	285	0	1	04	01	H5216_285_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
H5216	285	0	1	04	01	H5216_285_0	4			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	285	0	1	04	01	H5216_285_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		95.00	35.00		35.00
H5216	285	0	1	04	01	H5216_285_0	4			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																								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	285	0	1	04	01	H5216_285_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
H5216	287	0	1	04	01	H5216_287_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
H5216	287	0	1	04	01	H5216_287_0	4			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	287	0	1	04	01	H5216_287_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		95.00	35.00		35.00
H5216	287	0	1	04	01	H5216_287_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	287	0	1	04	01	H5216_287_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
H5216	288	0	1	04	01	H5216_288_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
H5216	288	0	1	04	01	H5216_288_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
H5216	288	0	1	04	01	H5216_288_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		95.00	35.00		35.00
H5216	288	0	1	04	01	H5216_288_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		35.00
H5216	288	0	1	04	01	H5216_288_0	4			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	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
H5216	289	0	1	04	01	H5216_289_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
H5216	289	0	1	04	01	H5216_289_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		95.00	35.00		35.00
H5216	289	0	1	04	01	H5216_289_0	4			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																								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		35.00
H5216	289	0	1	04	01	H5216_289_0	4			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	293	0	1	04	01	H5216_293_0	4			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				1.00	24		24																								24		24				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H5216	293	0	1	04	01	H5216_293_0	4			Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H5216	293	0	1	04	01	H5216_293_0	4			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				58.00	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	4			Non-Preferred Drug	4	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	293	0	1	04	01	H5216_293_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
H5216	300	0	1	04	01	H5216_300_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																									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	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
H5216	300	0	1	04	01	H5216_300_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		95.00	35.00		35.00
H5216	300	0	1	04	01	H5216_300_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
H5216	300	0	1	04	01	H5216_300_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
H5216	304	0	1	04	01	H5216_304_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
H5216	304	0	1	04	01	H5216_304_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
H5216	304	0	1	04	01	H5216_304_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		95.00	35.00		35.00
H5216	304	0	1	04	01	H5216_304_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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		105.00	35.00		35.00
H5216	304	0	1	04	01	H5216_304_0	4			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	305	0	1	04	01	H5216_305_0	3			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	3			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	305	0	1	04	01	H5216_305_0	3			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		95.00	35.00		35.00
H5216	305	0	1	04	01	H5216_305_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	305	0	1	04	01	H5216_305_0	3			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	306	0	1	04	01	H5216_306_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
H5216	306	0	1	04	01	H5216_306_0	4			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	306	0	1	04	01	H5216_306_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	34.00		102.00																									47.00		141.00				34.00		68.00				34.00				34.00		1.13				1.57	1.13	1.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				35.00		105.00	34.00		68.00	34.00		34.00
H5216	306	0	1	04	01	H5216_306_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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		35.00
H5216	306	0	1	04	01	H5216_306_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
H5216	307	0	1	04	01	H5216_307_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
H5216	307	0	1	04	01	H5216_307_0	4			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	307	0	1	04	01	H5216_307_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		95.00	35.00		35.00
H5216	307	0	1	04	01	H5216_307_0	4			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																								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	307	0	1	04	01	H5216_307_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
H5216	308	0	1	04	01	H5216_308_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
H5216	308	0	1	04	01	H5216_308_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
H5216	308	0	1	04	01	H5216_308_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		121.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		85.00	35.00		35.00
H5216	308	0	1	04	01	H5216_308_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	308	0	1	04	01	H5216_308_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
H5216	309	0	1	04	01	H5216_309_0	3			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	3			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	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																									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		70.00	35.00		35.00
H5216	309	0	1	04	01	H5216_309_0	3			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																								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	309	0	1	04	01	H5216_309_0	3			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
H5216	311	0	1	04	01	H5216_311_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
H5216	311	0	1	04	01	H5216_311_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
H5216	311	0	1	04	01	H5216_311_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		95.00	35.00		35.00
H5216	311	0	1	04	01	H5216_311_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H5216	311	0	1	04	01	H5216_311_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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	313	0	1	04	01	H5216_313_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	35		35																								45		45				35		35			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
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	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	314	0	1	04	01	H5216_314_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
H5216	314	0	1	04	01	H5216_314_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		80.00				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		70.00	35.00		35.00
H5216	314	0	1	04	01	H5216_314_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	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		35.00
H5216	314	0	1	04	01	H5216_314_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
H5216	316	1	1	04	01	H5216_316_1	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
H5216	316	1	1	04	01	H5216_316_1	4			Generic	4	11	1	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	316	1	1	04	01	H5216_316_1	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		95.00	35.00		35.00
H5216	316	1	1	04	01	H5216_316_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	316	1	1	04	01	H5216_316_1	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
H5216	316	3	1	04	01	H5216_316_3	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
H5216	316	3	1	04	01	H5216_316_3	4			Generic	4	11	1	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	316	3	1	04	01	H5216_316_3	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		95.00	35.00		35.00
H5216	316	3	1	04	01	H5216_316_3	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	316	3	1	04	01	H5216_316_3	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
H5216	317	0	1	04	01	H5216_317_0	3			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	317	0	1	04	01	H5216_317_0	3			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	317	0	1	04	01	H5216_317_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	317	0	1	04	01	H5216_317_0	3			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																								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		35.00
H5216	317	0	1	04	01	H5216_317_0	3			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	318	1	1	04	01	H5216_318_1	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
H5216	318	1	1	04	01	H5216_318_1	4			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	318	1	1	04	01	H5216_318_1	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		95.00	35.00		35.00
H5216	318	1	1	04	01	H5216_318_1	4			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																								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	318	1	1	04	01	H5216_318_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	318	2	1	04	01	H5216_318_2	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
H5216	318	2	1	04	01	H5216_318_2	4			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	318	2	1	04	01	H5216_318_2	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		95.00	35.00		35.00
H5216	318	2	1	04	01	H5216_318_2	4			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																								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	318	2	1	04	01	H5216_318_2	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	318	3	1	04	01	H5216_318_3	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
H5216	318	3	1	04	01	H5216_318_3	4			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	318	3	1	04	01	H5216_318_3	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		95.00	35.00		35.00
H5216	318	3	1	04	01	H5216_318_3	4			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																								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	318	3	1	04	01	H5216_318_3	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	319	0	1	04	01	H5216_319_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
H5216	319	0	1	04	01	H5216_319_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
H5216	319	0	1	04	01	H5216_319_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		95.00	35.00		35.00
H5216	319	0	1	04	01	H5216_319_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	29		29																								29		29				29		29			29			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
H5216	319	0	1	04	01	H5216_319_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
H5216	322	0	1	04	01	H5216_322_0	3			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	3			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	322	0	1	04	01	H5216_322_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	322	0	1	04	01	H5216_322_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				71.00	31		31																								31		31				31		31			31			31								Preferred Generic, Generic, 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	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										35.00						35.00			35.00			35.00		35.00
H5216	325	0	1	04	01	H5216_325_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
H5216	325	0	1	04	01	H5216_325_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
H5216	325	0	1	04	01	H5216_325_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		95.00	35.00		35.00
H5216	325	0	1	04	01	H5216_325_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	325	0	1	04	01	H5216_325_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
H5216	326	0	1	04	01	H5216_326_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	326	0	1	04	01	H5216_326_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
H5216	326	0	1	04	01	H5216_326_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		95.00	35.00		35.00
H5216	326	0	1	04	01	H5216_326_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	326	0	1	04	01	H5216_326_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	327	0	1	04	01	H5216_327_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
H5216	327	0	1	04	01	H5216_327_0	4			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	327	0	1	04	01	H5216_327_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		95.00	35.00		35.00
H5216	327	0	1	04	01	H5216_327_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				84.00	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	327	0	1	04	01	H5216_327_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
H5216	328	0	1	04	01	H5216_328_0	3			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	328	0	1	04	01	H5216_328_0	3			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	328	0	1	04	01	H5216_328_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	328	0	1	04	01	H5216_328_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				90.00	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		35.00
H5216	328	0	1	04	01	H5216_328_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										35.00						35.00			35.00			35.00		35.00
H5216	333	0	1	04	01	H5216_333_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
H5216	333	0	1	04	01	H5216_333_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
H5216	333	0	1	04	01	H5216_333_0	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		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		70.00	35.00		35.00
H5216	333	0	1	04	01	H5216_333_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	333	0	1	04	01	H5216_333_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
H5216	334	0	1	04	01	H5216_334_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, 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	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, 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	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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	334	0	1	04	01	H5216_334_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	47		47																								47		47				47		47			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		35.00
H5216	334	0	1	04	01	H5216_334_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
H5216	334	0	1	04	01	H5216_334_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				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	337	1	1	04	01	H5216_337_1	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
H5216	337	1	1	04	01	H5216_337_1	4			Generic	4	11	1	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	337	1	1	04	01	H5216_337_1	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		95.00	35.00		35.00
H5216	337	1	1	04	01	H5216_337_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	337	1	1	04	01	H5216_337_1	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
H5216	337	2	1	04	01	H5216_337_2	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
H5216	337	2	1	04	01	H5216_337_2	4			Generic	4	11	1	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	337	2	1	04	01	H5216_337_2	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		95.00	35.00		35.00
H5216	337	2	1	04	01	H5216_337_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	337	2	1	04	01	H5216_337_2	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
H5216	337	3	1	04	01	H5216_337_3	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
H5216	337	3	1	04	01	H5216_337_3	4			Generic	4	11	1	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	337	3	1	04	01	H5216_337_3	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		95.00	35.00		35.00
H5216	337	3	1	04	01	H5216_337_3	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	337	3	1	04	01	H5216_337_3	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
H5216	338	0	1	04	01	H5216_338_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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	338	0	1	04	01	H5216_338_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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	338	0	1	04	01	H5216_338_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									30.00		90.00				30.00		60.00				30.00				30.00		1.00				1.00	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00		90.00				30.00		90.00	30.00		60.00	30.00		30.00
H5216	338	0	1	04	01	H5216_338_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				51.00	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		105.00	35.00		35.00
H5216	338	0	1	04	01	H5216_338_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
H5216	339	0	1	04	01	H5216_339_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
H5216	339	0	1	04	01	H5216_339_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
H5216	339	0	1	04	01	H5216_339_0	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		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		70.00	35.00		35.00
H5216	339	0	1	04	01	H5216_339_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	339	0	1	04	01	H5216_339_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
H5216	340	0	1	04	01	H5216_340_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
H5216	340	0	1	04	01	H5216_340_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
H5216	340	0	1	04	01	H5216_340_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		95.00	35.00		35.00
H5216	340	0	1	04	01	H5216_340_0	4			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	340	0	1	04	01	H5216_340_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
H5216	345	0	1	04	01	H5216_345_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
H5216	345	0	1	04	01	H5216_345_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
H5216	345	0	1	04	01	H5216_345_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		95.00	35.00		35.00
H5216	345	0	1	04	01	H5216_345_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	345	0	1	04	01	H5216_345_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
H5216	346	0	1	04	01	H5216_346_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
H5216	346	0	1	04	01	H5216_346_0	4			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	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		95.00	35.00		35.00
H5216	346	0	1	04	01	H5216_346_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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	346	0	1	04	01	H5216_346_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
H5216	347	0	1	04	01	H5216_347_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
H5216	347	0	1	04	01	H5216_347_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
H5216	347	0	1	04	01	H5216_347_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		95.00	35.00		35.00
H5216	347	0	1	04	01	H5216_347_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H5216	347	0	1	04	01	H5216_347_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
H5216	350	0	1	04	01	H5216_350_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
H5216	350	0	1	04	01	H5216_350_0	4			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	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	37.00		111.00																									47.00		141.00				37.00		74.00				37.00				37.00		1.23				1.57	1.23	1.19	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
H5216	350	0	1	04	01	H5216_350_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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	350	0	1	04	01	H5216_350_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
H5216	351	0	1	04	01	H5216_351_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
H5216	351	0	1	04	01	H5216_351_0	4			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	351	0	1	04	01	H5216_351_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		95.00	35.00		35.00
H5216	351	0	1	04	01	H5216_351_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	39		39																								39		39				39		39			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
H5216	351	0	1	04	01	H5216_351_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
H5216	352	0	1	04	01	H5216_352_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
H5216	352	0	1	04	01	H5216_352_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	352	0	1	04	01	H5216_352_0	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		95.00	35.00		35.00
H5216	352	0	1	04	01	H5216_352_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	352	0	1	04	01	H5216_352_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
H5216	353	0	1	04	01	H5216_353_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
H5216	353	0	1	04	01	H5216_353_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	353	0	1	04	01	H5216_353_0	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		95.00	35.00		35.00
H5216	353	0	1	04	01	H5216_353_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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		105.00	35.00		35.00
H5216	353	0	1	04	01	H5216_353_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
H5216	358	0	1	04	01	H5216_358_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
H5216	358	0	1	04	01	H5216_358_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	358	0	1	04	01	H5216_358_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		95.00	35.00		35.00
H5216	358	0	1	04	01	H5216_358_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	42		42																								42		42				42		42			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
H5216	358	0	1	04	01	H5216_358_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
H5216	359	0	1	04	01	H5216_359_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	359	0	1	04	01	H5216_359_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				70.00	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	359	0	1	04	01	H5216_359_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										35.00						35.00			35.00			35.00		35.00
H5216	360	0	1	04	01	H5216_360_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
H5216	360	0	1	04	01	H5216_360_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	360	0	1	04	01	H5216_360_0	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		95.00	35.00		35.00
H5216	360	0	1	04	01	H5216_360_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	36		36																								36		36				36		36			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
H5216	360	0	1	04	01	H5216_360_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
H5216	362	0	1	04	01	H5216_362_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	362	0	1	04	01	H5216_362_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	362	0	1	04	01	H5216_362_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				34.00	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	362	0	1	04	01	H5216_362_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				33.00	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	362	0	1	04	01	H5216_362_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	363	0	1	04	01	H5216_363_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																									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	4			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	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		95.00	35.00		35.00
H5216	363	0	1	04	01	H5216_363_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				91.00	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		35.00
H5216	363	0	1	04	01	H5216_363_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
H5216	364	0	1	04	01	H5216_364_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
H5216	364	0	1	04	01	H5216_364_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
H5216	364	0	1	04	01	H5216_364_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		95.00	35.00		35.00
H5216	364	0	1	04	01	H5216_364_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H5216	364	0	1	04	01	H5216_364_0	4			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	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, Select Care Drugs										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	4			Generic	4	11	1	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, Select Care Drugs										9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H5216	366	0	1	04	01	H5216_366_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	366	0	1	04	01	H5216_366_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	40		40																								40		40				40		40			40			40								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	366	0	1	04	01	H5216_366_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5216	366	0	1	04	01	H5216_366_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
H5216	368	0	1	04	01	H5216_368_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
H5216	368	0	1	04	01	H5216_368_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
H5216	368	0	1	04	01	H5216_368_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		95.00	35.00		35.00
H5216	368	0	1	04	01	H5216_368_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	368	0	1	04	01	H5216_368_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
H5216	369	0	1	04	01	H5216_369_0	6			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				0.00	0		0																								25		25				0		0			0			0								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
H5216	369	0	1	04	01	H5216_369_0	6			Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				3.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H5216	369	0	1	04	01	H5216_369_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				36.00	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	369	0	1	04	01	H5216_369_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				36.00	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	369	0	1	04	01	H5216_369_0	6			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
H5216	371	0	1	04	01	H5216_371_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	371	0	1	04	01	H5216_371_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	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
H5216	371	0	1	04	01	H5216_371_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		70.00	35.00		35.00
H5216	371	0	1	04	01	H5216_371_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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	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	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, Select Care Drugs										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	4			Generic	4	11	1	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, Select Care Drugs										9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H5216	372	0	1	04	01	H5216_372_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	372	0	1	04	01	H5216_372_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	41		41																								41		41				41		41			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		35.00
H5216	372	0	1	04	01	H5216_372_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5216	372	0	1	04	01	H5216_372_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
H5216	375	0	1	04	01	H5216_375_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, 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	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, Select Care Drugs										10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	375	0	1	04	01	H5216_375_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	375	0	1	04	01	H5216_375_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	42		42																								42		42				42		42			42			42								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	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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5216	375	0	1	04	01	H5216_375_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																									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	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																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	4			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	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		95.00	35.00		35.00
H5216	376	0	1	04	01	H5216_376_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	376	0	1	04	01	H5216_376_0	4			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
H5216	378	0	1	04	01	H5216_378_0	3			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	3			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	378	0	1	04	01	H5216_378_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5216	378	0	1	04	01	H5216_378_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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	378	0	1	04	01	H5216_378_0	3			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	380	0	1	04	01	H5216_380_0	3			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	3			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	380	0	1	04	01	H5216_380_0	3			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		95.00	35.00		35.00
H5216	380	0	1	04	01	H5216_380_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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	380	0	1	04	01	H5216_380_0	3			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	382	0	1	04	01	H5216_382_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
H5216	382	0	1	04	01	H5216_382_0	4			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	382	0	1	04	01	H5216_382_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		95.00	35.00		35.00
H5216	382	0	1	04	01	H5216_382_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	42		42																								42		42				42		42			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
H5216	382	0	1	04	01	H5216_382_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
H5216	383	0	1	04	01	H5216_383_0	4			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	4			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	383	0	1	04	01	H5216_383_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		95.00	35.00		35.00
H5216	383	0	1	04	01	H5216_383_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	37		37																								37		37				37		37			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
H5216	383	0	1	04	01	H5216_383_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
H5216	384	0	1	04	01	H5216_384_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
H5216	384	0	1	04	01	H5216_384_0	4			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	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		95.00	35.00		35.00
H5216	384	0	1	04	01	H5216_384_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	384	0	1	04	01	H5216_384_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
H5216	387	1	1	04	01	H5216_387_1	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
H5216	387	1	1	04	01	H5216_387_1	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
H5216	387	1	1	04	01	H5216_387_1	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		95.00	35.00		35.00
H5216	387	1	1	04	01	H5216_387_1	4			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																								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	387	1	1	04	01	H5216_387_1	4			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	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
H5216	387	2	1	04	01	H5216_387_2	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
H5216	387	2	1	04	01	H5216_387_2	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		95.00	35.00		35.00
H5216	387	2	1	04	01	H5216_387_2	4			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																								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	387	2	1	04	01	H5216_387_2	4			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	4			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	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
H5216	389	0	1	04	01	H5216_389_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		95.00	35.00		35.00
H5216	389	0	1	04	01	H5216_389_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	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		35.00
H5216	389	0	1	04	01	H5216_389_0	4			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	390	0	1	04	01	H5216_390_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
H5216	390	0	1	04	01	H5216_390_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
H5216	390	0	1	04	01	H5216_390_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		95.00	35.00		35.00
H5216	390	0	1	04	01	H5216_390_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				86.00	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	390	0	1	04	01	H5216_390_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
H5216	391	0	1	04	01	H5216_391_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
H5216	391	0	1	04	01	H5216_391_0	4			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	391	0	1	04	01	H5216_391_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		95.00	35.00		35.00
H5216	391	0	1	04	01	H5216_391_0	4			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																								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	391	0	1	04	01	H5216_391_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
H5216	393	0	1	04	01	H5216_393_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
H5216	393	0	1	04	01	H5216_393_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
H5216	393	0	1	04	01	H5216_393_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	393	0	1	04	01	H5216_393_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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
H5216	393	0	1	04	01	H5216_393_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
H5216	395	0	1	04	01	H5216_395_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
H5216	395	0	1	04	01	H5216_395_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
H5216	395	0	1	04	01	H5216_395_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		95.00	35.00		35.00
H5216	395	0	1	04	01	H5216_395_0	4			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																								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	395	0	1	04	01	H5216_395_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
H5216	396	0	1	04	01	H5216_396_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
H5216	396	0	1	04	01	H5216_396_0	4			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	396	0	1	04	01	H5216_396_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		95.00	35.00		35.00
H5216	396	0	1	04	01	H5216_396_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H5216	396	0	1	04	01	H5216_396_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
H5216	397	0	1	04	01	H5216_397_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
H5216	397	0	1	04	01	H5216_397_0	4			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	397	0	1	04	01	H5216_397_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		95.00	35.00		35.00
H5216	397	0	1	04	01	H5216_397_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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	397	0	1	04	01	H5216_397_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
H5216	399	0	1	04	01	H5216_399_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
H5216	399	0	1	04	01	H5216_399_0	4			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	399	0	1	04	01	H5216_399_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		95.00	35.00		35.00
H5216	399	0	1	04	01	H5216_399_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	399	0	1	04	01	H5216_399_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
H5216	400	0	1	04	01	H5216_400_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	400	0	1	04	01	H5216_400_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	400	0	1	04	01	H5216_400_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				34.00	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	400	0	1	04	01	H5216_400_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				33.00	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	400	0	1	04	01	H5216_400_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	401	0	1	04	01	H5216_401_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	401	0	1	04	01	H5216_401_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	401	0	1	04	01	H5216_401_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				37.00	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	401	0	1	04	01	H5216_401_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				35.00	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	401	0	1	04	01	H5216_401_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	402	0	1	04	01	H5216_402_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	402	0	1	04	01	H5216_402_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	402	0	1	04	01	H5216_402_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				34.00	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	402	0	1	04	01	H5216_402_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				32.00	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	402	0	1	04	01	H5216_402_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	403	0	1	04	01	H5216_403_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
H5216	403	0	1	04	01	H5216_403_0	4			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	403	0	1	04	01	H5216_403_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		95.00	35.00		35.00
H5216	403	0	1	04	01	H5216_403_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H5216	403	0	1	04	01	H5216_403_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
H5216	404	0	1	04	01	H5216_404_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
H5216	404	0	1	04	01	H5216_404_0	4			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	404	0	1	04	01	H5216_404_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		95.00	35.00		35.00
H5216	404	0	1	04	01	H5216_404_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	404	0	1	04	01	H5216_404_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
H5216	405	0	1	04	01	H5216_405_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
H5216	405	0	1	04	01	H5216_405_0	4			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	405	0	1	04	01	H5216_405_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		95.00	35.00		35.00
H5216	405	0	1	04	01	H5216_405_0	4			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																								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	405	0	1	04	01	H5216_405_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
H5216	406	0	1	04	01	H5216_406_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
H5216	406	0	1	04	01	H5216_406_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
H5216	406	0	1	04	01	H5216_406_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		95.00	35.00		35.00
H5216	406	0	1	04	01	H5216_406_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5216	406	0	1	04	01	H5216_406_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
H5216	407	0	1	04	01	H5216_407_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
H5216	407	0	1	04	01	H5216_407_0	4			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	407	0	1	04	01	H5216_407_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		95.00	35.00		35.00
H5216	407	0	1	04	01	H5216_407_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	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		35.00
H5216	407	0	1	04	01	H5216_407_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
H5216	408	0	1	04	01	H5216_408_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
H5216	408	0	1	04	01	H5216_408_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
H5216	408	0	1	04	01	H5216_408_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		95.00	35.00		35.00
H5216	408	0	1	04	01	H5216_408_0	4			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																								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		35.00
H5216	408	0	1	04	01	H5216_408_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
H5216	409	0	1	04	01	H5216_409_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
H5216	409	0	1	04	01	H5216_409_0	4			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	409	0	1	04	01	H5216_409_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		95.00	35.00		35.00
H5216	409	0	1	04	01	H5216_409_0	4			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																								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		35.00
H5216	409	0	1	04	01	H5216_409_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
H5216	410	0	1	04	01	H5216_410_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
H5216	410	0	1	04	01	H5216_410_0	4			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	410	0	1	04	01	H5216_410_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		95.00	35.00		35.00
H5216	410	0	1	04	01	H5216_410_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				94.00	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		35.00
H5216	410	0	1	04	01	H5216_410_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
H5216	411	0	1	04	01	H5216_411_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
H5216	411	0	1	04	01	H5216_411_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
H5216	411	0	1	04	01	H5216_411_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		95.00	35.00		35.00
H5216	411	0	1	04	01	H5216_411_0	4			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																								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	411	0	1	04	01	H5216_411_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
H5216	412	0	1	04	01	H5216_412_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
H5216	412	0	1	04	01	H5216_412_0	4			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	412	0	1	04	01	H5216_412_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		95.00	35.00		35.00
H5216	412	0	1	04	01	H5216_412_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5216	412	0	1	04	01	H5216_412_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
H5216	413	0	1	04	01	H5216_413_0	6			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		90				1	2				30		90	30		31				2.00	17		17																								18		18				17		0			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H5216	413	0	1	04	01	H5216_413_0	6			Generic	4	11	1	1	2	1	110		01		110	1	30		90				2	2				30		90	30		31				3.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H5216	413	0	1	04	01	H5216_413_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				32.00	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	413	0	1	04	01	H5216_413_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				31.00	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	413	0	1	04	01	H5216_413_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	414	0	1	04	01	H5216_414_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	414	0	1	04	01	H5216_414_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	414	0	1	04	01	H5216_414_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	414	0	1	04	01	H5216_414_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	414	0	1	04	01	H5216_414_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5216	414	0	1	04	01	H5216_414_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
H5216	415	0	1	04	01	H5216_415_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	415	0	1	04	01	H5216_415_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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	415	0	1	04	01	H5216_415_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	415	0	1	04	01	H5216_415_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	415	0	1	04	01	H5216_415_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5216	415	0	1	04	01	H5216_415_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
H5216	416	0	1	04	01	H5216_416_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	416	0	1	04	01	H5216_416_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	416	0	1	04	01	H5216_416_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				35.00	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	416	0	1	04	01	H5216_416_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				33.00	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	416	0	1	04	01	H5216_416_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	417	0	1	04	01	H5216_417_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	417	0	1	04	01	H5216_417_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
H5216	417	0	1	04	01	H5216_417_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		95.00	35.00		35.00
H5216	417	0	1	04	01	H5216_417_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H5216	417	0	1	04	01	H5216_417_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	419	0	1	04	01	H5216_419_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	419	0	1	04	01	H5216_419_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	419	0	1	04	01	H5216_419_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				35.00	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	419	0	1	04	01	H5216_419_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				33.00	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	419	0	1	04	01	H5216_419_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	421	0	1	04	01	H5216_421_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
H5216	421	0	1	04	01	H5216_421_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
H5216	421	0	1	04	01	H5216_421_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		95.00	35.00		35.00
H5216	421	0	1	04	01	H5216_421_0	4			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																								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		35.00
H5216	421	0	1	04	01	H5216_421_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
H5216	423	0	1	04	01	H5216_423_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
H5216	423	0	1	04	01	H5216_423_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
H5216	423	0	1	04	01	H5216_423_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		95.00	35.00		35.00
H5216	423	0	1	04	01	H5216_423_0	4			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																								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		35.00
H5216	423	0	1	04	01	H5216_423_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
H5216	424	0	1	04	01	H5216_424_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
H5216	424	0	1	04	01	H5216_424_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
H5216	424	0	1	04	01	H5216_424_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		95.00	35.00		35.00
H5216	424	0	1	04	01	H5216_424_0	4			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																								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	424	0	1	04	01	H5216_424_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
H5216	425	0	1	04	01	H5216_425_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
H5216	425	0	1	04	01	H5216_425_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
H5216	425	0	1	04	01	H5216_425_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		95.00	35.00		35.00
H5216	425	0	1	04	01	H5216_425_0	4			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																								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	425	0	1	04	01	H5216_425_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
H5216	426	0	1	04	01	H5216_426_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
H5216	426	0	1	04	01	H5216_426_0	4			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	426	0	1	04	01	H5216_426_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		95.00	35.00		35.00
H5216	426	0	1	04	01	H5216_426_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	426	0	1	04	01	H5216_426_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
H5216	428	1	1	04	01	H5216_428_1	3			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	428	1	1	04	01	H5216_428_1	3			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	428	1	1	04	01	H5216_428_1	3			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		95.00	35.00		35.00
H5216	428	1	1	04	01	H5216_428_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	428	1	1	04	01	H5216_428_1	3			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	428	2	1	04	01	H5216_428_2	3			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	428	2	1	04	01	H5216_428_2	3			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	428	2	1	04	01	H5216_428_2	3			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		95.00	35.00		35.00
H5216	428	2	1	04	01	H5216_428_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	428	2	1	04	01	H5216_428_2	3			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	428	3	1	04	01	H5216_428_3	3			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	428	3	1	04	01	H5216_428_3	3			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	428	3	1	04	01	H5216_428_3	3			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		95.00	35.00		35.00
H5216	428	3	1	04	01	H5216_428_3	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	428	3	1	04	01	H5216_428_3	3			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	429	0	1	04	01	H5216_429_0	3			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	429	0	1	04	01	H5216_429_0	3			Generic	4	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	429	0	1	04	01	H5216_429_0	3			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		95.00	35.00		35.00
H5216	429	0	1	04	01	H5216_429_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	429	0	1	04	01	H5216_429_0	3			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	430	0	1	04	01	H5216_430_0	3			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	430	0	1	04	01	H5216_430_0	3			Generic	4	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	430	0	1	04	01	H5216_430_0	3			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		95.00	35.00		35.00
H5216	430	0	1	04	01	H5216_430_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H5216	430	0	1	04	01	H5216_430_0	3			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	431	0	1	04	01	H5216_431_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
H5216	431	0	1	04	01	H5216_431_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	431	0	1	04	01	H5216_431_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		95.00	35.00		35.00
H5216	431	0	1	04	01	H5216_431_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	42		42																								42		42				42		42			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
H5216	431	0	1	04	01	H5216_431_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
H5216	432	0	1	04	01	H5216_432_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
H5216	432	0	1	04	01	H5216_432_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	432	0	1	04	01	H5216_432_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		95.00	35.00		35.00
H5216	432	0	1	04	01	H5216_432_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	42		42																								42		42				42		42			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
H5216	432	0	1	04	01	H5216_432_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
H5216	433	0	1	04	01	H5216_433_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
H5216	433	0	1	04	01	H5216_433_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	433	0	1	04	01	H5216_433_0	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		95.00	35.00		35.00
H5216	433	0	1	04	01	H5216_433_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5216	433	0	1	04	01	H5216_433_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
H5216	434	0	1	04	01	H5216_434_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
H5216	434	0	1	04	01	H5216_434_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
H5216	434	0	1	04	01	H5216_434_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		70.00	35.00		35.00
H5216	434	0	1	04	01	H5216_434_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	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		35.00
H5216	434	0	1	04	01	H5216_434_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
H5216	435	1	1	04	01	H5216_435_1	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
H5216	435	1	1	04	01	H5216_435_1	4			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	435	1	1	04	01	H5216_435_1	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	435	1	1	04	01	H5216_435_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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		105.00	35.00		35.00
H5216	435	1	1	04	01	H5216_435_1	4			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
H5216	435	2	1	04	01	H5216_435_2	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
H5216	435	2	1	04	01	H5216_435_2	4			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	435	2	1	04	01	H5216_435_2	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	435	2	1	04	01	H5216_435_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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		105.00	35.00		35.00
H5216	435	2	1	04	01	H5216_435_2	4			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
H5216	435	3	1	04	01	H5216_435_3	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
H5216	435	3	1	04	01	H5216_435_3	4			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	435	3	1	04	01	H5216_435_3	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5216	435	3	1	04	01	H5216_435_3	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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		105.00	35.00		35.00
H5216	435	3	1	04	01	H5216_435_3	4			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
H5216	438	0	1	04	01	H5216_438_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
H5216	438	0	1	04	01	H5216_438_0	4			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	438	0	1	04	01	H5216_438_0	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		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		70.00	35.00		35.00
H5216	438	0	1	04	01	H5216_438_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	438	0	1	04	01	H5216_438_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
H5216	439	0	1	04	01	H5216_439_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
H5216	439	0	1	04	01	H5216_439_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
H5216	439	0	1	04	01	H5216_439_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		70.00	35.00		35.00
H5216	439	0	1	04	01	H5216_439_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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		35.00
H5216	439	0	1	04	01	H5216_439_0	4			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	440	0	1	04	01	H5216_440_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
H5216	440	0	1	04	01	H5216_440_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
H5216	440	0	1	04	01	H5216_440_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		70.00	35.00		35.00
H5216	440	0	1	04	01	H5216_440_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	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		35.00
H5216	440	0	1	04	01	H5216_440_0	4			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	443	0	1	04	01	H5216_443_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, Select Care Drugs										0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	443	0	1	04	01	H5216_443_0	4			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	443	0	1	04	01	H5216_443_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	443	0	1	04	01	H5216_443_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5216	443	0	1	04	01	H5216_443_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5216	443	0	1	04	01	H5216_443_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				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	444	0	1	04	01	H5216_444_0	5			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
H5216	444	0	1	04	01	H5216_444_0	5			Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				3.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
H5216	444	0	1	04	01	H5216_444_0	5			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				34.00	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	444	0	1	04	01	H5216_444_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				32.00	26		26																								26		26				26		26			26			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
H5216	444	0	1	04	01	H5216_444_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	445	0	1	04	01	H5216_445_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
H5216	445	0	1	04	01	H5216_445_0	4			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	445	0	1	04	01	H5216_445_0	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		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		70.00	35.00		35.00
H5216	445	0	1	04	01	H5216_445_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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		35.00
H5216	445	0	1	04	01	H5216_445_0	4			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										35.00						35.00			35.00			35.00		35.00
H5216	446	0	1	04	01	H5216_446_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	446	0	1	04	01	H5216_446_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	446	0	1	04	01	H5216_446_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				34.00	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	446	0	1	04	01	H5216_446_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				33.00	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	446	0	1	04	01	H5216_446_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	447	0	1	04	01	H5216_447_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	447	0	1	04	01	H5216_447_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	447	0	1	04	01	H5216_447_0	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				34.00	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	447	0	1	04	01	H5216_447_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				32.00	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	447	0	1	04	01	H5216_447_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	448	0	1	04	01	H5216_448_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
H5216	448	0	1	04	01	H5216_448_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
H5216	448	0	1	04	01	H5216_448_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		95.00	35.00		35.00
H5216	448	0	1	04	01	H5216_448_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H5216	448	0	1	04	01	H5216_448_0	4			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	449	0	1	04	01	H5216_449_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
H5216	449	0	1	04	01	H5216_449_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
H5216	449	0	1	04	01	H5216_449_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		95.00	35.00		35.00
H5216	449	0	1	04	01	H5216_449_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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		35.00
H5216	449	0	1	04	01	H5216_449_0	4			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	450	0	1	04	01	H5216_450_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
H5216	450	0	1	04	01	H5216_450_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
H5216	450	0	1	04	01	H5216_450_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		95.00	35.00		35.00
H5216	450	0	1	04	01	H5216_450_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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		35.00
H5216	450	0	1	04	01	H5216_450_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
H5216	451	0	1	04	01	H5216_451_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
H5216	451	0	1	04	01	H5216_451_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
H5216	451	0	1	04	01	H5216_451_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		95.00	35.00		35.00
H5216	451	0	1	04	01	H5216_451_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5216	451	0	1	04	01	H5216_451_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
H5216	452	0	1	04	01	H5216_452_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	452	0	1	04	01	H5216_452_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	452	0	1	04	01	H5216_452_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	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	452	0	1	04	01	H5216_452_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	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		105.00	35.00		35.00
H5216	452	0	1	04	01	H5216_452_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
H5232	001	0	1	04	01	H5232_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																			0.00		0.00																0.00				0.00		0.00			0.00			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	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
H5232	001	0	1	04	01	H5232_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																			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	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
H5232	001	0	1	04	01	H5232_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				304.84	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	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																								
H5244	001	0	1	01	01	H5244_001_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																								
H5244	001	0	1	01	01	H5244_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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5244	001	0	1	01	01	H5244_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											87.94	50	50	50				87.94	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
H5244	001	0	1	01	01	H5244_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																								
H5244	002	0	1	01	01	H5244_002_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																								
H5244	002	0	1	01	01	H5244_002_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																								
H5244	002	0	1	01	01	H5244_002_0	9			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, 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
H5244	002	0	1	01	01	H5244_002_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											82.17	50	50	50				82.17	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
H5244	002	0	1	01	01	H5244_002_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																								
H5244	004	0	1	01	01	H5244_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5244	004	0	1	01	01	H5244_004_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																								
H5244	004	0	1	01	01	H5244_004_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											106.53	25	25	25				106.53	24	24	24										25	25	25				24	24	24			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
H5244	004	0	1	01	01	H5244_004_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											86.12	45	45	45				86.12	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
H5244	004	0	1	01	01	H5244_004_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																								
H5244	005	0	1	01	01	H5244_005_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																								
H5244	005	0	1	01	01	H5244_005_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																								
H5244	005	0	1	01	01	H5244_005_0	9			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5244	005	0	1	01	01	H5244_005_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											87.14	50	50	50				87.14	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
H5244	005	0	1	01	01	H5244_005_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																								
H5253	004	0	1	02	01	H5253_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																								
H5253	004	0	1	02	01	H5253_004_0	8			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																								
H5253	004	0	1	02	01	H5253_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
H5253	004	0	1	02	01	H5253_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	004	0	1	02	01	H5253_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				186.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				177.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				176.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				191.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				157.00	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
H5253	035	0	1	02	01	H5253_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																								
H5253	035	0	1	02	01	H5253_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																								
H5253	035	0	1	02	01	H5253_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
H5253	035	0	1	02	01	H5253_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	035	0	1	02	01	H5253_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	036	0	1	02	01	H5253_036_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				165.00	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
H5253	037	0	1	02	01	H5253_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																								
H5253	037	0	1	02	01	H5253_037_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																								
H5253	037	0	1	02	01	H5253_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
H5253	037	0	1	02	01	H5253_037_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	037	0	1	02	01	H5253_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				192.00	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
H5253	038	0	1	02	01	H5253_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																								
H5253	038	0	1	02	01	H5253_038_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																								
H5253	038	0	1	02	01	H5253_038_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	038	0	1	02	01	H5253_038_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	038	0	1	02	01	H5253_038_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				182.00	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
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			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	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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	047	0	1	02	01	H5253_047_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				198.00	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
H5253	048	0	1	02	01	H5253_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																								
H5253	048	0	1	02	01	H5253_048_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																								
H5253	048	0	1	02	01	H5253_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
H5253	048	0	1	02	01	H5253_048_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	048	0	1	02	01	H5253_048_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				160.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				151.00	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
H5253	064	0	1	02	01	H5253_064_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																								
H5253	064	0	1	02	01	H5253_064_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																								
H5253	064	0	1	02	01	H5253_064_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	064	0	1	02	01	H5253_064_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	064	0	1	02	01	H5253_064_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				160.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				189.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				183.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				166.00	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
H5253	081	0	1	02	01	H5253_081_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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	081	0	1	02	01	H5253_081_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	081	0	1	02	01	H5253_081_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	081	0	1	02	01	H5253_081_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				185.00	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
H5253	082	0	1	02	01	H5253_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																								
H5253	082	0	1	02	01	H5253_082_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	082	0	1	02	01	H5253_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
H5253	082	0	1	02	01	H5253_082_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	082	0	1	02	01	H5253_082_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				169.00	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
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			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	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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	083	0	1	02	01	H5253_083_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				220.00	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
H5253	084	0	1	02	01	H5253_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																								
H5253	084	0	1	02	01	H5253_084_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	084	0	1	02	01	H5253_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
H5253	084	0	1	02	01	H5253_084_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	084	0	1	02	01	H5253_084_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				175.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				193.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				178.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				166.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				179.00	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
H5253	100	0	1	02	01	H5253_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																								
H5253	100	0	1	02	01	H5253_100_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	100	0	1	02	01	H5253_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
H5253	100	0	1	02	01	H5253_100_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	100	0	1	02	01	H5253_100_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				184.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				167.00	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
H5253	104	0	1	02	01	H5253_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																								
H5253	104	0	1	02	01	H5253_104_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	104	0	1	02	01	H5253_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
H5253	104	0	1	02	01	H5253_104_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	104	0	1	02	01	H5253_104_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				197.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				192.00	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
H5253	107	1	1	02	01	H5253_107_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	107	1	1	02	01	H5253_107_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																								
H5253	107	1	1	02	01	H5253_107_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	107	1	1	02	01	H5253_107_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	107	1	1	02	01	H5253_107_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				168.00	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
H5253	107	3	1	02	01	H5253_107_3	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	3	1	02	01	H5253_107_3	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	3	1	02	01	H5253_107_3	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	3	1	02	01	H5253_107_3	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	107	3	1	02	01	H5253_107_3	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H5253	108	1	1	02	01	H5253_108_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	108	1	1	02	01	H5253_108_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																								
H5253	108	1	1	02	01	H5253_108_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	108	1	1	02	01	H5253_108_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	108	1	1	02	01	H5253_108_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H5253	108	2	1	02	01	H5253_108_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	108	2	1	02	01	H5253_108_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	108	2	1	02	01	H5253_108_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	108	2	1	02	01	H5253_108_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	108	2	1	02	01	H5253_108_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H5253	108	3	1	02	01	H5253_108_3	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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	108	3	1	02	01	H5253_108_3	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	108	3	1	02	01	H5253_108_3	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	108	3	1	02	01	H5253_108_3	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H5253	108	4	1	02	01	H5253_108_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																								
H5253	108	4	1	02	01	H5253_108_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																								
H5253	108	4	1	02	01	H5253_108_4	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	108	4	1	02	01	H5253_108_4	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	108	4	1	02	01	H5253_108_4	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
H5253	109	1	1	02	01	H5253_109_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	109	1	1	02	01	H5253_109_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																								
H5253	109	1	1	02	01	H5253_109_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	109	1	1	02	01	H5253_109_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	109	1	1	02	01	H5253_109_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H5253	109	2	1	02	01	H5253_109_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	109	2	1	02	01	H5253_109_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	109	2	1	02	01	H5253_109_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	109	2	1	02	01	H5253_109_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	109	2	1	02	01	H5253_109_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H5253	109	4	1	02	01	H5253_109_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																								
H5253	109	4	1	02	01	H5253_109_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																								
H5253	109	4	1	02	01	H5253_109_4	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	109	4	1	02	01	H5253_109_4	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	109	4	1	02	01	H5253_109_4	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				148.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				187.00	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
H5253	111	2	1	02	01	H5253_111_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	111	2	1	02	01	H5253_111_2	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	111	2	1	02	01	H5253_111_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	111	2	1	02	01	H5253_111_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	111	2	1	02	01	H5253_111_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				194.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				194.00	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
H5253	117	0	1	02	01	H5253_117_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	117	0	1	02	01	H5253_117_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																								
H5253	117	0	1	02	01	H5253_117_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	117	0	1	02	01	H5253_117_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	117	0	1	02	01	H5253_117_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				171.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				176.00	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
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			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	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	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	121	0	1	02	01	H5253_121_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				190.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				188.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				188.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				167.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				167.00	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
H5253	126	1	1	02	01	H5253_126_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	126	1	1	02	01	H5253_126_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																								
H5253	126	1	1	02	01	H5253_126_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	126	1	1	02	01	H5253_126_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	126	1	1	02	01	H5253_126_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				156.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				156.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				182.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				187.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				162.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				150.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				132.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				162.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				160.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				155.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				182.00	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
H5253	142	0	1	02	01	H5253_142_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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	142	0	1	02	01	H5253_142_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	142	0	1	02	01	H5253_142_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	142	0	1	02	01	H5253_142_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				169.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				169.00	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
H5253	145	0	1	02	01	H5253_145_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	145	0	1	02	01	H5253_145_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																								
H5253	145	0	1	02	01	H5253_145_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	145	0	1	02	01	H5253_145_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	145	0	1	02	01	H5253_145_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
H5253	146	0	1	02	01	H5253_146_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	146	0	1	02	01	H5253_146_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	146	0	1	02	01	H5253_146_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	146	0	1	02	01	H5253_146_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	146	0	1	02	01	H5253_146_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H5253	147	0	1	02	01	H5253_147_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	147	0	1	02	01	H5253_147_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	147	0	1	02	01	H5253_147_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	147	0	1	02	01	H5253_147_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	147	0	1	02	01	H5253_147_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H5253	148	0	1	02	01	H5253_148_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	148	0	1	02	01	H5253_148_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	148	0	1	02	01	H5253_148_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	148	0	1	02	01	H5253_148_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	148	0	1	02	01	H5253_148_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				197.00	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
H5253	150	0	1	02	01	H5253_150_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	150	0	1	02	01	H5253_150_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	150	0	1	02	01	H5253_150_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	150	0	1	02	01	H5253_150_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	150	0	1	02	01	H5253_150_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H5253	154	0	1	02	01	H5253_154_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	154	0	1	02	01	H5253_154_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																								
H5253	154	0	1	02	01	H5253_154_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	154	0	1	02	01	H5253_154_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	154	0	1	02	01	H5253_154_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
H5253	155	0	1	02	01	H5253_155_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	155	0	1	02	01	H5253_155_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	155	0	1	02	01	H5253_155_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
H5253	155	0	1	02	01	H5253_155_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	155	0	1	02	01	H5253_155_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				189.00	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
H5253	157	1	1	02	01	H5253_157_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	157	1	1	02	01	H5253_157_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	157	1	1	02	01	H5253_157_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	157	1	1	02	01	H5253_157_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	157	1	1	02	01	H5253_157_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
H5253	157	2	1	02	01	H5253_157_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	157	2	1	02	01	H5253_157_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	157	2	1	02	01	H5253_157_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	157	2	1	02	01	H5253_157_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	157	2	1	02	01	H5253_157_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
H5253	159	0	1	02	01	H5253_159_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	159	0	1	02	01	H5253_159_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	159	0	1	02	01	H5253_159_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	159	0	1	02	01	H5253_159_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	159	0	1	02	01	H5253_159_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				166.00	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
H5253	161	0	1	02	01	H5253_161_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	161	0	1	02	01	H5253_161_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	161	0	1	02	01	H5253_161_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
H5253	161	0	1	02	01	H5253_161_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	161	0	1	02	01	H5253_161_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
H5253	162	1	1	02	01	H5253_162_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	162	1	1	02	01	H5253_162_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																								
H5253	162	1	1	02	01	H5253_162_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	162	1	1	02	01	H5253_162_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	162	1	1	02	01	H5253_162_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H5253	162	2	1	02	01	H5253_162_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	162	2	1	02	01	H5253_162_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	162	2	1	02	01	H5253_162_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	162	2	1	02	01	H5253_162_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	162	2	1	02	01	H5253_162_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H5253	164	1	1	02	01	H5253_164_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	164	1	1	02	01	H5253_164_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	164	1	1	02	01	H5253_164_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	164	1	1	02	01	H5253_164_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	164	1	1	02	01	H5253_164_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				154.00	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
H5253	164	2	1	02	01	H5253_164_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	164	2	1	02	01	H5253_164_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	164	2	1	02	01	H5253_164_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	164	2	1	02	01	H5253_164_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	164	2	1	02	01	H5253_164_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				154.00	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
H5253	165	1	1	02	01	H5253_165_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	165	1	1	02	01	H5253_165_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	165	1	1	02	01	H5253_165_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	165	1	1	02	01	H5253_165_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	165	1	1	02	01	H5253_165_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				157.00	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
H5253	165	2	1	02	01	H5253_165_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	165	2	1	02	01	H5253_165_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	165	2	1	02	01	H5253_165_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	165	2	1	02	01	H5253_165_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	165	2	1	02	01	H5253_165_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				157.00	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
H5253	168	0	1	02	01	H5253_168_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	168	0	1	02	01	H5253_168_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	168	0	1	02	01	H5253_168_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
H5253	168	0	1	02	01	H5253_168_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	168	0	1	02	01	H5253_168_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				159.00	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
H5253	169	0	1	02	01	H5253_169_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	169	0	1	02	01	H5253_169_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	169	0	1	02	01	H5253_169_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	169	0	1	02	01	H5253_169_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	169	0	1	02	01	H5253_169_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H5253	171	0	1	02	01	H5253_171_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	171	0	1	02	01	H5253_171_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																								
H5253	171	0	1	02	01	H5253_171_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	171	0	1	02	01	H5253_171_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	171	0	1	02	01	H5253_171_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H5253	172	0	1	02	01	H5253_172_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	172	0	1	02	01	H5253_172_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	172	0	1	02	01	H5253_172_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	172	0	1	02	01	H5253_172_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	172	0	1	02	01	H5253_172_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H5253	173	0	1	02	01	H5253_173_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	173	0	1	02	01	H5253_173_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	173	0	1	02	01	H5253_173_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	173	0	1	02	01	H5253_173_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	173	0	1	02	01	H5253_173_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				160.00	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
H5253	174	0	1	02	01	H5253_174_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	174	0	1	02	01	H5253_174_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	174	0	1	02	01	H5253_174_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	174	0	1	02	01	H5253_174_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	174	0	1	02	01	H5253_174_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				194.00	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
H5253	175	0	1	02	01	H5253_175_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	175	0	1	02	01	H5253_175_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	175	0	1	02	01	H5253_175_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
H5253	175	0	1	02	01	H5253_175_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	175	0	1	02	01	H5253_175_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H5253	176	0	1	02	01	H5253_176_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	176	0	1	02	01	H5253_176_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	176	0	1	02	01	H5253_176_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
H5253	176	0	1	02	01	H5253_176_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	176	0	1	02	01	H5253_176_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H5253	178	0	1	02	01	H5253_178_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	178	0	1	02	01	H5253_178_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	178	0	1	02	01	H5253_178_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	178	0	1	02	01	H5253_178_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	178	0	1	02	01	H5253_178_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				178.00	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
H5253	179	0	1	02	01	H5253_179_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	179	0	1	02	01	H5253_179_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	179	0	1	02	01	H5253_179_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
H5253	179	0	1	02	01	H5253_179_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	179	0	1	02	01	H5253_179_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H5253	180	0	1	02	01	H5253_180_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	180	0	1	02	01	H5253_180_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	180	0	1	02	01	H5253_180_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
H5253	180	0	1	02	01	H5253_180_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	180	0	1	02	01	H5253_180_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				169.00	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
H5253	182	0	1	02	01	H5253_182_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	182	0	1	02	01	H5253_182_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	182	0	1	02	01	H5253_182_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
H5253	182	0	1	02	01	H5253_182_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	182	0	1	02	01	H5253_182_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				169.00	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
H5253	183	0	1	02	01	H5253_183_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	183	0	1	02	01	H5253_183_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	183	0	1	02	01	H5253_183_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
H5253	183	0	1	02	01	H5253_183_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	183	0	1	02	01	H5253_183_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				174.00	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
H5253	185	0	1	02	01	H5253_185_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	185	0	1	02	01	H5253_185_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	185	0	1	02	01	H5253_185_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	185	0	1	02	01	H5253_185_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	185	0	1	02	01	H5253_185_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H5253	186	0	1	02	01	H5253_186_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	186	0	1	02	01	H5253_186_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	186	0	1	02	01	H5253_186_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
H5253	186	0	1	02	01	H5253_186_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	186	0	1	02	01	H5253_186_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
H5253	187	0	1	02	01	H5253_187_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	187	0	1	02	01	H5253_187_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	187	0	1	02	01	H5253_187_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	187	0	1	02	01	H5253_187_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	187	0	1	02	01	H5253_187_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				168.00	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
H5253	188	0	1	02	01	H5253_188_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	188	0	1	02	01	H5253_188_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	188	0	1	02	01	H5253_188_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
H5253	188	0	1	02	01	H5253_188_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	188	0	1	02	01	H5253_188_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				166.00	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
H5253	189	0	1	02	01	H5253_189_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	189	0	1	02	01	H5253_189_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																								
H5253	189	0	1	02	01	H5253_189_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
H5253	189	0	1	02	01	H5253_189_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	189	0	1	02	01	H5253_189_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H5253	190	0	1	02	01	H5253_190_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	190	0	1	02	01	H5253_190_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	190	0	1	02	01	H5253_190_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
H5253	190	0	1	02	01	H5253_190_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	190	0	1	02	01	H5253_190_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
H5253	192	0	1	02	01	H5253_192_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	192	0	1	02	01	H5253_192_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	192	0	1	02	01	H5253_192_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
H5253	192	0	1	02	01	H5253_192_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	192	0	1	02	01	H5253_192_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H5253	193	1	1	02	01	H5253_193_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	193	1	1	02	01	H5253_193_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																								
H5253	193	1	1	02	01	H5253_193_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										25.00		75.00						75.00			65.00	25.00		25.00
H5253	193	1	1	02	01	H5253_193_1	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	193	1	1	02	01	H5253_193_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				159.00	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
H5253	193	2	1	02	01	H5253_193_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	193	2	1	02	01	H5253_193_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																								
H5253	193	2	1	02	01	H5253_193_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										25.00		75.00						75.00			65.00	25.00		25.00
H5253	193	2	1	02	01	H5253_193_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	193	2	1	02	01	H5253_193_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				159.00	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
H5253	195	0	1	02	01	H5253_195_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	195	0	1	02	01	H5253_195_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	195	0	1	02	01	H5253_195_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
H5253	195	0	1	02	01	H5253_195_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	195	0	1	02	01	H5253_195_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H5253	196	0	1	02	01	H5253_196_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	196	0	1	02	01	H5253_196_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	196	0	1	02	01	H5253_196_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
H5253	196	0	1	02	01	H5253_196_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	196	0	1	02	01	H5253_196_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				171.00	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
H5253	197	0	1	02	01	H5253_197_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	197	0	1	02	01	H5253_197_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	197	0	1	02	01	H5253_197_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
H5253	197	0	1	02	01	H5253_197_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	197	0	1	02	01	H5253_197_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H5253	198	0	1	02	01	H5253_198_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	198	0	1	02	01	H5253_198_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	198	0	1	02	01	H5253_198_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	198	0	1	02	01	H5253_198_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5253	198	0	1	02	01	H5253_198_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				180.00	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
H5262	001	0	1	01	01	H5262_001_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	12.50																			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																								
H5262	001	0	1	01	01	H5262_001_0	7			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	37.50																			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, Select Care Drugs																								
H5262	001	0	1	01	01	H5262_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				105.43	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
H5262	001	0	1	01	01	H5262_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				57.58	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	001	0	1	01	01	H5262_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																								
H5262	001	0	1	01	01	H5262_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	003	0	1	01	01	H5262_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	5.00	10.00	12.50																			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																								
H5262	003	0	1	01	01	H5262_003_0	7			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	37.50																			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, Select Care Drugs																								
H5262	003	0	1	01	01	H5262_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				118.10	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
H5262	003	0	1	01	01	H5262_003_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				66.56	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	003	0	1	01	01	H5262_003_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																								
H5262	003	0	1	01	01	H5262_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	007	0	1	01	01	H5262_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	5.00	10.00	12.50																			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																								
H5262	007	0	1	01	01	H5262_007_0	6			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	37.50																			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, Select Care Drugs																								
H5262	007	0	1	01	01	H5262_007_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				106.59	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
H5262	007	0	1	01	01	H5262_007_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				66.45	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	007	0	1	01	01	H5262_007_0	6			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																								
H5262	007	0	1	01	01	H5262_007_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	008	0	1	01	01	H5262_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	5.00	10.00	12.50																			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																								
H5262	008	0	1	01	01	H5262_008_0	6			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	37.50																			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, Select Care Drugs																								
H5262	008	0	1	01	01	H5262_008_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				115.65	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
H5262	008	0	1	01	01	H5262_008_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				63.10	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	008	0	1	01	01	H5262_008_0	6			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																								
H5262	008	0	1	01	01	H5262_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	011	0	1	01	01	H5262_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	011	0	1	01	01	H5262_011_0	6			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	12.50																			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																								
H5262	011	0	1	01	01	H5262_011_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				107.64	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
H5262	011	0	1	01	01	H5262_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				60.12	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	011	0	1	01	01	H5262_011_0	6			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, Select Care Drugs																								
H5262	011	0	1	01	01	H5262_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	012	0	1	01	01	H5262_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	012	0	1	01	01	H5262_012_0	6			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	12.50																			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																								
H5262	012	0	1	01	01	H5262_012_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				110.94	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
H5262	012	0	1	01	01	H5262_012_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				69.39	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	012	0	1	01	01	H5262_012_0	6			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, Select Care Drugs																								
H5262	012	0	1	01	01	H5262_012_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	018	0	1	01	01	H5262_018_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	12.50																			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																								
H5262	018	0	1	01	01	H5262_018_0	6			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	37.50																			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, Select Care Drugs																								
H5262	018	0	1	01	01	H5262_018_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				115.88	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
H5262	018	0	1	01	01	H5262_018_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				65.45	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	018	0	1	01	01	H5262_018_0	6			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																								
H5262	018	0	1	01	01	H5262_018_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	019	0	1	01	01	H5262_019_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	12.50																			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																								
H5262	019	0	1	01	01	H5262_019_0	6			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	37.50																			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, Select Care Drugs																								
H5262	019	0	1	01	01	H5262_019_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				116.91	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
H5262	019	0	1	01	01	H5262_019_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				65.61	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	019	0	1	01	01	H5262_019_0	6			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																								
H5262	019	0	1	01	01	H5262_019_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	021	0	1	01	01	H5262_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	5.00	10.00	12.50																			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																								
H5262	021	0	1	01	01	H5262_021_0	6			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	37.50																			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, Select Care Drugs																								
H5262	021	0	1	01	01	H5262_021_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				125.18	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
H5262	021	0	1	01	01	H5262_021_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				72.70	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	021	0	1	01	01	H5262_021_0	6			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, Select Care Drugs																								
H5262	021	0	1	01	01	H5262_021_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	023	0	1	01	01	H5262_023_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	12.50																			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																								
H5262	023	0	1	01	01	H5262_023_0	6			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	37.50																			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, Select Care Drugs																								
H5262	023	0	1	01	01	H5262_023_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				117.59	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
H5262	023	0	1	01	01	H5262_023_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				69.93	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	023	0	1	01	01	H5262_023_0	6			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																								
H5262	023	0	1	01	01	H5262_023_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	024	0	1	01	01	H5262_024_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, Select Care Drugs																								
H5262	024	0	1	01	01	H5262_024_0	6			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	12.50																			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																								
H5262	024	0	1	01	01	H5262_024_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				104.67	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
H5262	024	0	1	01	01	H5262_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				62.29	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	024	0	1	01	01	H5262_024_0	6			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, Select Care Drugs																								
H5262	024	0	1	01	01	H5262_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	026	0	1	01	01	H5262_026_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	12.50																			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																								
H5262	026	0	1	01	01	H5262_026_0	6			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	37.50																			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, Select Care Drugs																								
H5262	026	0	1	01	01	H5262_026_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				103.25	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		35.00
H5262	026	0	1	01	01	H5262_026_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				56.31	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H5262	026	0	1	01	01	H5262_026_0	6			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																								
H5262	026	0	1	01	01	H5262_026_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	029	0	1	01	01	H5262_029_0	5		N	Preferred Generic	2	01	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				2.33	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	029	0	1	01	01	H5262_029_0	5		N	Generic	2	01	1	1	2	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				9.78	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	029	0	1	01	01	H5262_029_0	5		N	Preferred Brand	2	11	1	1	3	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				127.56	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
H5262	029	0	1	01	01	H5262_029_0	5		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				122.45	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
H5262	029	0	1	01	01	H5262_029_0	5		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, Select Care Drugs																								
H5262	029	0	1	01	01	H5262_029_0	5		N	Select Care Drugs	2	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	030	0	1	01	01	H5262_030_0	5		N	Preferred Generic	2	01	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				2.32	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	030	0	1	01	01	H5262_030_0	5		N	Generic	2	01	1	1	2	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				9.71	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	030	0	1	01	01	H5262_030_0	5		N	Preferred Brand	2	11	1	1	3	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				125.65	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
H5262	030	0	1	01	01	H5262_030_0	5		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				119.29	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
H5262	030	0	1	01	01	H5262_030_0	5		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, Select Care Drugs																								
H5262	030	0	1	01	01	H5262_030_0	5		N	Select Care Drugs	2	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	031	0	1	01	01	H5262_031_0	5		N	Preferred Generic	2	01	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				2.32	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	031	0	1	01	01	H5262_031_0	5		N	Generic	2	01	1	1	2	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				9.71	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5262	031	0	1	01	01	H5262_031_0	5		N	Preferred Brand	2	11	1	1	3	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				125.66	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
H5262	031	0	1	01	01	H5262_031_0	5		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				119.30	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
H5262	031	0	1	01	01	H5262_031_0	5		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, Select Care Drugs																								
H5262	031	0	1	01	01	H5262_031_0	5		N	Select Care Drugs	2	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5273	001	0	1	01	01	H5273_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										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	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					5.00	10.00	15.00					5.00	10.00	10.00																15.00				5.00			0.50	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										15.00	30.00	45.00	5.00	10.00	15.00	5.00	10.00	10.00				15.00		5.00
H5273	001	0	1	01	01	H5273_001_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											67.24	25	25	25				69.48	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											74.87	50	50	50				50.81	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H5273	001	0	1	01	01	H5273_001_0	6			Vaccines	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																								
H5280	001	0	1	48	05	H5280_001_0	7			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	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	7			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	100				2	2	31	60	100				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	7			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31						2	2	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	4			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	011	0	1	01	01	H5294_011_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	20.00	30.00				0.00	0.00	0.00				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																								
H5294	011	0	1	01	01	H5294_011_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											173.44	25	25	25				173.44	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
H5294	011	0	1	01	01	H5294_011_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											93.94	42	42	42				93.94	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
H5294	011	0	1	01	01	H5294_011_0	4			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																								
H5294	011	0	1	01	01	H5294_011_0	4			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	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	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	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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	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	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.88	25	25	25				152.53	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
H5294	013	0	1	01	01	H5294_013_0	6			Non-Preferred Drug	3	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	200.00				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
H5294	013	0	1	01	01	H5294_013_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																								
H5294	013	0	1	01	01	H5294_013_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	016	0	1	01	01	H5294_016_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5294	016	0	1	01	01	H5294_016_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5294	016	0	1	01	01	H5294_016_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.28	24	24	24				148.81	23	23	23										24	24	24				23	23	23			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
H5294	016	0	1	01	01	H5294_016_0	5			Non-Preferred Drug	3	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	200.00				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
H5294	016	0	1	01	01	H5294_016_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																								
H5294	016	0	1	01	01	H5294_016_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H5294	017	0	1	01	01	H5294_017_0	5			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	017	0	1	01	01	H5294_017_0	5			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																								
H5294	017	0	1	01	01	H5294_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											166.37	25	25	25				166.37	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
H5294	017	0	1	01	01	H5294_017_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											63.31	34	34	34				63.31	34	34	34										34	34	34				34	34	34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	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, Select Care Drugs																								
H5294	017	0	1	01	01	H5294_017_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																								
H5294	018	0	1	01	01	H5294_018_0	5			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	5			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																								
H5294	018	0	1	01	01	H5294_018_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.92	25	25	25				164.92	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
H5294	018	0	1	01	01	H5294_018_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											50.83	36	36	36				50.83	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	018	0	1	01	01	H5294_018_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, Select Care Drugs																								
H5294	018	0	1	01	01	H5294_018_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																								
H5294	019	0	1	01	01	H5294_019_0	5			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	019	0	1	01	01	H5294_019_0	5			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																								
H5294	019	0	1	01	01	H5294_019_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											170.80	25	25	25				170.80	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
H5294	019	0	1	01	01	H5294_019_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											79.05	44	44	44				79.05	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
H5294	019	0	1	01	01	H5294_019_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, Select Care Drugs																								
H5294	019	0	1	01	01	H5294_019_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																								
H5294	020	0	1	01	01	H5294_020_0	5			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	5			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																								
H5294	020	0	1	01	01	H5294_020_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											167.15	25	25	25				167.15	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
H5294	020	0	1	01	01	H5294_020_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											52.55	36	36	36				52.55	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	020	0	1	01	01	H5294_020_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, Select Care Drugs																								
H5294	020	0	1	01	01	H5294_020_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																								
H5296	003	0	1	02	01	H5296_003_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
H5296	003	0	1	02	01	H5296_003_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	Preferred 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	9			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	003	0	1	02	01	H5296_003_0	9			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	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				486.11	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	9			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	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
H5296	005	0	1	02	01	H5296_005_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	Preferred 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	9			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	9			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	005	0	1	02	01	H5296_005_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				480.65	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	9			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	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
H5296	006	0	1	01	01	H5296_006_0	8			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
H5296	006	0	1	01	01	H5296_006_0	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				433.25	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	8			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	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
H5296	007	0	1	01	01	H5296_007_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										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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				544.74	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	8			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	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
H5296	008	0	1	01	01	H5296_008_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	Preferred 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	9			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	9			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	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				431.37	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	9			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																								
H5299	001	0	1	01	01	H5299_001_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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
H5299	001	0	1	01	01	H5299_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				38.00	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
H5299	001	0	1	01	01	H5299_001_0	7			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
H5299	002	0	1	01	01	H5299_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										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	7			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	002	0	1	01	01	H5299_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				78.00	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
H5299	002	0	1	01	01	H5299_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				39.00	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
H5299	002	0	1	01	01	H5299_002_0	7			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
H5299	012	0	1	01	01	H5299_012_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										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	7			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	012	0	1	01	01	H5299_012_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.00	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
H5299	012	0	1	01	01	H5299_012_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				41.00	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
H5299	012	0	1	01	01	H5299_012_0	7			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
H5302	022	0	1	01	01	H5302_022_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5302	022	0	1	01	01	H5302_022_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5302	022	0	1	01	01	H5302_022_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.30	22	22	22				42.06	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	022	0	1	01	01	H5302_022_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.72	25	25	25				47.05	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
H5302	022	0	1	01	01	H5302_022_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											367.89	25						330.04	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
H5302	023	0	1	01	01	H5302_023_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5302	023	0	1	01	01	H5302_023_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5302	023	0	1	01	01	H5302_023_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.68	22	22	22				42.31	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	023	0	1	01	01	H5302_023_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.48	25	25	25				46.51	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
H5302	023	0	1	01	01	H5302_023_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											367.87	25						328.31	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
H5309	001	0	1	04	01	H5309_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5309	001	0	1	04	01	H5309_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5309	001	0	1	04	01	H5309_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.95	24	24	24				101.73	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
H5309	001	0	1	04	01	H5309_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	25	25	25				34.81	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
H5309	001	0	1	04	01	H5309_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.73	25						674.31	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
H5309	002	0	1	04	01	H5309_002_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5309	002	0	1	04	01	H5309_002_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5309	002	0	1	04	01	H5309_002_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.95	24	24	24				101.73	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
H5309	002	0	1	04	01	H5309_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	25	25	25				34.81	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
H5309	002	0	1	04	01	H5309_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.73	25						674.47	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
H5309	003	0	1	04	01	H5309_003_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5309	003	0	1	04	01	H5309_003_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5309	003	0	1	04	01	H5309_003_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.95	24	24	24				101.73	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
H5309	003	0	1	04	01	H5309_003_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	25	25	25				34.81	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
H5309	003	0	1	04	01	H5309_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.73	25						674.51	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				192.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				174.00	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
H5322	042	0	1	02	01	H5322_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																								
H5322	042	0	1	02	01	H5322_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																								
H5322	042	0	1	02	01	H5322_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
H5322	042	0	1	02	01	H5322_042_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5322	042	0	1	02	01	H5322_042_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				161.00	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
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			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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				193.00	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
H5361	001	0	1	04	01	H5361_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								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	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					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																								
H5361	001	0	1	04	01	H5361_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											72.00	25	25	25				70.00	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	70.00	70.00				35.00		35.00
H5361	001	0	1	04	01	H5361_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											40.00	50	50	50				32.00	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	70.00				35.00		35.00
H5361	001	0	1	04	01	H5361_001_0	5			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	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					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																								
H5361	002	0	1	04	01	H5361_002_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	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																								
H5361	002	0	1	04	01	H5361_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											65.00	25	25	25				68.00	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	70.00	70.00				35.00		35.00
H5361	002	0	1	04	01	H5361_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											43.00	50	50	50				41.00	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	70.00				35.00		35.00
H5361	002	0	1	04	01	H5361_002_0	5			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	003	0	1	04	01	H5361_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								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	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					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																								
H5361	003	0	1	04	01	H5361_003_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											92.00	25	25	25				92.00	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	70.00	70.00				35.00		35.00
H5361	003	0	1	04	01	H5361_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											54.00	50	50	50				40.00	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	70.00				35.00		35.00
H5361	003	0	1	04	01	H5361_003_0	5			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	5			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	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					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																								
H5361	004	0	1	04	01	H5361_004_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											92.00	25	25	25				93.00	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	70.00	70.00				35.00		35.00
H5361	004	0	1	04	01	H5361_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											54.00	50	50	50				41.00	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	70.00				35.00		35.00
H5361	004	0	1	04	01	H5361_004_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5377	002	0	1	02	01	H5377_002_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
H5377	002	0	1	02	01	H5377_002_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
H5377	002	0	1	02	01	H5377_002_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		95.00	35.00		35.00
H5377	002	0	1	02	01	H5377_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5377	002	0	1	02	01	H5377_002_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
H5386	003	0	1	01	01	H5386_003_0	10			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	10			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	10			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	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	90.00	180.00	270.00																			90.00	180.00	180.00																90.00				90.00		3.00			3.00			2.65	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	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				516.94	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	10			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	10			Preferred Generic	4	01	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	10			Generic	4	11	1	2	2	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																5.00				5.00		0.17			0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5386	004	0	1	01	01	H5386_004_0	10			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	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	90.00	180.00	270.00																			90.00	180.00	180.00																90.00				90.00		3.00			3.00			2.65	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	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				509.21	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	10			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	10			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	10			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	10			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	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	90.00	180.00	270.00																			90.00	180.00	180.00																90.00				90.00		3.00			3.00			2.65	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	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				508.92	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	10			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	02	01	H5398_002_0	5			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	02	01	H5398_002_0	5			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																								
H5398	002	0	1	02	01	H5398_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.17	25	25	25				159.17	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
H5398	002	0	1	02	01	H5398_002_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											47.44	38	38	38				47.44	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
H5398	002	0	1	02	01	H5398_002_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, Select Care Drugs																								
H5398	002	0	1	02	01	H5398_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5398	004	0	1	02	01	H5398_004_0	5			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	02	01	H5398_004_0	5			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																								
H5398	004	0	1	02	01	H5398_004_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.20	25	25	25				153.20	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	02	01	H5398_004_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											65.47	41	41	41				65.47	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
H5398	004	0	1	02	01	H5398_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, Select Care Drugs																								
H5398	004	0	1	02	01	H5398_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		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			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	4			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
H5410	018	0	1	01	01	H5410_018_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	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
H5410	018	0	1	01	01	H5410_018_0	4			Preferred Brand	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
H5410	018	0	1	01	01	H5410_018_0	4			Non-Preferred Drug	4	11	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	018	0	1	01	01	H5410_018_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											924.15	33						677.55	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
H5410	024	0	1	01	01	H5410_024_0	4			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
H5410	024	0	1	01	01	H5410_024_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	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
H5410	024	0	1	01	01	H5410_024_0	4			Preferred Brand	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	024	0	1	01	01	H5410_024_0	4			Non-Preferred Drug	4	11	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	024	0	1	01	01	H5410_024_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											769.28	33						597.15	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
H5410	026	0	1	01	01	H5410_026_0	4			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
H5410	026	0	1	01	01	H5410_026_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	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
H5410	026	0	1	01	01	H5410_026_0	4			Preferred Brand	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	026	0	1	01	01	H5410_026_0	4			Non-Preferred Drug	4	11	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	026	0	1	01	01	H5410_026_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1006.21	33						624.12	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
H5410	027	0	1	01	01	H5410_027_0	4			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
H5410	027	0	1	01	01	H5410_027_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	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
H5410	027	0	1	01	01	H5410_027_0	4			Preferred Brand	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	027	0	1	01	01	H5410_027_0	4			Non-Preferred Drug	4	11	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	027	0	1	01	01	H5410_027_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											978.92	33						775.33	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
H5410	028	0	1	01	01	H5410_028_0	4			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
H5410	028	0	1	01	01	H5410_028_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	028	0	1	01	01	H5410_028_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											937.40	33						626.23	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
H5410	029	0	1	01	01	H5410_029_0	4			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
H5410	029	0	1	01	01	H5410_029_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					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	4			Preferred Brand	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	029	0	1	01	01	H5410_029_0	4			Non-Preferred Drug	4	11	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	029	0	1	01	01	H5410_029_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											994.27	33						591.64	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
H5410	030	0	1	01	01	H5410_030_0	4			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
H5410	030	0	1	01	01	H5410_030_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	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
H5410	030	0	1	01	01	H5410_030_0	4			Preferred Brand	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	030	0	1	01	01	H5410_030_0	4			Non-Preferred Drug	4	11	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	030	0	1	01	01	H5410_030_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1111.69	33						627.11	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
H5410	037	0	1	01	01	H5410_037_0	4			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
H5410	037	0	1	01	01	H5410_037_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	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
H5410	037	0	1	01	01	H5410_037_0	4			Preferred Brand	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	037	0	1	01	01	H5410_037_0	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1042.40	33						613.92	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	039	0	1	01	01	H5410_039_0	4			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
H5410	039	0	1	01	01	H5410_039_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	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
H5410	039	0	1	01	01	H5410_039_0	4			Preferred Brand	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	039	0	1	01	01	H5410_039_0	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											767.07	33						534.48	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
H5410	040	0	1	01	01	H5410_040_0	4			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
H5410	040	0	1	01	01	H5410_040_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	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
H5410	040	0	1	01	01	H5410_040_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	040	0	1	01	01	H5410_040_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											904.90	33						511.96	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
H5410	041	0	1	01	01	H5410_041_0	4			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
H5410	041	0	1	01	01	H5410_041_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					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	4			Preferred Brand	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	041	0	1	01	01	H5410_041_0	4			Non-Preferred Drug	4	11	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	041	0	1	01	01	H5410_041_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											930.53	33						503.76	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
H5410	043	0	1	01	01	H5410_043_0	4			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
H5410	043	0	1	01	01	H5410_043_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	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
H5410	043	0	1	01	01	H5410_043_0	4			Preferred Brand	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	043	0	1	01	01	H5410_043_0	4			Non-Preferred Drug	4	11	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	043	0	1	01	01	H5410_043_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1079.31	33						712.22	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
H5410	044	0	1	01	01	H5410_044_0	4			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
H5410	044	0	1	01	01	H5410_044_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	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
H5410	044	0	1	01	01	H5410_044_0	4			Preferred Brand	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	044	0	1	01	01	H5410_044_0	4			Non-Preferred Drug	4	11	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	044	0	1	01	01	H5410_044_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											953.93	33						591.02	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	048	0	1	01	01	H5410_048_0	4			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
H5410	048	0	1	01	01	H5410_048_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					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	048	0	1	01	01	H5410_048_0	4			Preferred Brand	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	048	0	1	01	01	H5410_048_0	4			Non-Preferred Drug	4	11	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	048	0	1	01	01	H5410_048_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											987.88	33						650.28	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
H5410	050	0	1	01	01	H5410_050_0	4			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
H5410	050	0	1	01	01	H5410_050_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	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
H5410	050	0	1	01	01	H5410_050_0	4			Preferred Brand	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	050	0	1	01	01	H5410_050_0	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.56	33						523.23	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
H5410	051	0	1	01	01	H5410_051_0	4			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
H5410	051	0	1	01	01	H5410_051_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					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	051	0	1	01	01	H5410_051_0	4			Preferred Brand	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	051	0	1	01	01	H5410_051_0	4			Non-Preferred Drug	4	11	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	051	0	1	01	01	H5410_051_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											963.85	33						636.02	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	052	0	1	01	01	H5410_052_0	4			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
H5410	052	0	1	01	01	H5410_052_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	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
H5410	052	0	1	01	01	H5410_052_0	4			Preferred Brand	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	052	0	1	01	01	H5410_052_0	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											843.51	33						587.03	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
H5410	053	0	1	01	01	H5410_053_0	4			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
H5410	053	0	1	01	01	H5410_053_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	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
H5410	053	0	1	01	01	H5410_053_0	4			Preferred Brand	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	053	0	1	01	01	H5410_053_0	4			Non-Preferred Drug	4	11	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	053	0	1	01	01	H5410_053_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											906.31	33						573.17	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	054	0	1	01	01	H5410_054_0	4			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
H5410	054	0	1	01	01	H5410_054_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	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
H5410	054	0	1	01	01	H5410_054_0	4			Preferred Brand	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	054	0	1	01	01	H5410_054_0	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											835.86	33						538.15	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
H5420	001	0	1	01	01	H5420_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5420	001	0	1	01	01	H5420_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5420	001	0	1	01	01	H5420_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H5420	001	0	1	01	01	H5420_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30						2	2	30						30		31	65.00																					65.00																		65.00				65.00		2.16			2.17			2.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5420	001	0	1	01	01	H5420_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				283.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5420	003	0	1	01	01	H5420_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																								
H5420	003	0	1	01	01	H5420_003_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																								
H5420	003	0	1	01	01	H5420_003_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
H5420	003	0	1	01	01	H5420_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5420	003	0	1	01	01	H5420_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				224.00	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
H5420	014	0	1	01	01	H5420_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5420	014	0	1	01	01	H5420_014_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5420	014	0	1	01	01	H5420_014_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H5420	014	0	1	01	01	H5420_014_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30						2	2	30						30		31	65.00																					65.00																		65.00				65.00		2.16			2.17			2.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5420	014	0	1	01	01	H5420_014_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				231.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5422	011	0	1	02	01	H5422_011_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																								
H5422	011	0	1	02	01	H5422_011_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H5422	011	0	1	02	01	H5422_011_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.65	20	20	20				58.65	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	70.00				35.00		35.00
H5422	011	0	1	02	01	H5422_011_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											47.80	35	35	35				47.80	35	35	35				35	35	35															35			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
H5422	011	0	1	02	01	H5422_011_0	7			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																								
H5422	011	0	1	02	01	H5422_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																								
H5422	013	0	1	02	01	H5422_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5422	013	0	1	02	01	H5422_013_0	7			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				13.14	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5422	013	0	1	02	01	H5422_013_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				70.69	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
H5422	013	0	1	02	01	H5422_013_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				38.95	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
H5422	013	0	1	02	01	H5422_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5422	013	0	1	02	01	H5422_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5422	015	0	1	02	01	H5422_015_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																								
H5422	015	0	1	02	01	H5422_015_0	9			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																								
H5422	015	0	1	02	01	H5422_015_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.93	25	25	25				43.14	20	20	20				20	20	20															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		35.00
H5422	015	0	1	02	01	H5422_015_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											62.37	25	25	25				62.37	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		35.00
H5422	015	0	1	02	01	H5422_015_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																								
H5422	015	0	1	02	01	H5422_015_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5425	001	0	1	01	01	H5425_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								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																								
H5425	001	0	1	01	01	H5425_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	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																								
H5425	001	0	1	01	01	H5425_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	001	0	1	01	01	H5425_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											81.88	50	50	50				81.88	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
H5425	001	0	1	01	01	H5425_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																								
H5425	005	0	1	01	01	H5425_005_0	9			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																								
H5425	005	0	1	01	01	H5425_005_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	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																								
H5425	005	0	1	01	01	H5425_005_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	005	0	1	01	01	H5425_005_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											82.62	50	50	50				82.62	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
H5425	005	0	1	01	01	H5425_005_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																								
H5425	006	0	1	01	01	H5425_006_0	13			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																								
H5425	006	0	1	01	01	H5425_006_0	13			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																								
H5425	006	0	1	01	01	H5425_006_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					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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	006	0	1	01	01	H5425_006_0	13			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											78.73	50	50	50				78.73	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
H5425	006	0	1	01	01	H5425_006_0	13			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5425	007	0	1	01	01	H5425_007_0	9			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																								
H5425	007	0	1	01	01	H5425_007_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	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																								
H5425	007	0	1	01	01	H5425_007_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	007	0	1	01	01	H5425_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											80.49	50	50	50				80.49	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
H5425	007	0	1	01	01	H5425_007_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																								
H5425	008	0	1	01	01	H5425_008_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																								
H5425	008	0	1	01	01	H5425_008_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																								
H5425	008	0	1	01	01	H5425_008_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	008	0	1	01	01	H5425_008_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											69.19	50	50	50				69.19	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
H5425	008	0	1	01	01	H5425_008_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																								
H5425	009	0	1	01	01	H5425_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								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																								
H5425	009	0	1	01	01	H5425_009_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	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																								
H5425	009	0	1	01	01	H5425_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	009	0	1	01	01	H5425_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											64.21	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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5425	009	0	1	01	01	H5425_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																								
H5425	019	0	1	01	01	H5425_019_0	9			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																								
H5425	019	0	1	01	01	H5425_019_0	9			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																								
H5425	019	0	1	01	01	H5425_019_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	019	0	1	01	01	H5425_019_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											68.22	50	50	50				68.22	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	105.00	35.00		35.00
H5425	019	0	1	01	01	H5425_019_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																								
H5425	034	0	1	01	01	H5425_034_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																								
H5425	034	0	1	01	01	H5425_034_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																								
H5425	034	0	1	01	01	H5425_034_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	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										0.00	0.00	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.23	50	50	50				86.23	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
H5425	034	0	1	01	01	H5425_034_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																								
H5425	065	0	1	01	01	H5425_065_0	10			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																								
H5425	065	0	1	01	01	H5425_065_0	10			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																								
H5425	065	0	1	01	01	H5425_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								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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	065	0	1	01	01	H5425_065_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											67.17	50	50	50				67.17	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
H5425	065	0	1	01	01	H5425_065_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																								
H5425	069	0	1	01	01	H5425_069_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																								
H5425	069	0	1	01	01	H5425_069_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																								
H5425	069	0	1	01	01	H5425_069_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	069	0	1	01	01	H5425_069_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											64.15	50	50	50				64.15	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
H5425	069	0	1	01	01	H5425_069_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																								
H5425	070	0	1	01	01	H5425_070_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																								
H5425	070	0	1	01	01	H5425_070_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																								
H5425	070	0	1	01	01	H5425_070_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	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										0.00	0.00	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	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.34	50	50	50				85.34	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
H5425	070	0	1	01	01	H5425_070_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																								
H5425	075	0	1	01	01	H5425_075_0	10			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																								
H5425	075	0	1	01	01	H5425_075_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					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																								
H5425	075	0	1	01	01	H5425_075_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	075	0	1	01	01	H5425_075_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											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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5425	075	0	1	01	01	H5425_075_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																								
H5425	076	0	1	01	01	H5425_076_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																								
H5425	076	0	1	01	01	H5425_076_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					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																								
H5425	076	0	1	01	01	H5425_076_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	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										0.00	0.00	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	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.98	50	50	50				85.98	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
H5425	076	0	1	01	01	H5425_076_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																								
H5425	082	0	1	01	01	H5425_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								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																								
H5425	082	0	1	01	01	H5425_082_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	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																								
H5425	082	0	1	01	01	H5425_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	082	0	1	01	01	H5425_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											75.15	50	50	50				75.15	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
H5425	082	0	1	01	01	H5425_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																								
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																								
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																								
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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	084	0	1	01	01	H5425_084_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											77.83	50	50	50				77.83	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
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																								
H5425	085	0	1	01	01	H5425_085_0	9			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																								
H5425	085	0	1	01	01	H5425_085_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	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																								
H5425	085	0	1	01	01	H5425_085_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	085	0	1	01	01	H5425_085_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											63.90	50	50	50				63.90	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
H5425	085	0	1	01	01	H5425_085_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																								
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																								
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																								
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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, 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
H5425	086	0	1	01	01	H5425_086_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											83.94	50	50	50				83.94	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
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																								
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																								
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																								
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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, 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
H5425	087	0	1	01	01	H5425_087_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											78.54	50	50	50				78.54	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
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																								
H5425	091	0	1	02	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																								
H5425	091	0	1	02	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																								
H5425	091	0	1	02	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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, 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
H5425	091	0	1	02	01	H5425_091_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											84.13	50	50	50				84.13	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
H5425	091	0	1	02	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																								
H5425	092	0	1	01	01	H5425_092_0	9			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																								
H5425	092	0	1	01	01	H5425_092_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	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																								
H5425	092	0	1	01	01	H5425_092_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	092	0	1	01	01	H5425_092_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											67.06	50	50	50				67.06	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
H5425	092	0	1	01	01	H5425_092_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																								
H5425	096	0	1	01	01	H5425_096_0	9			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																								
H5425	096	0	1	01	01	H5425_096_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	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																								
H5425	096	0	1	01	01	H5425_096_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	096	0	1	01	01	H5425_096_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											87.34	50	50	50				87.34	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
H5425	096	0	1	01	01	H5425_096_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																								
H5425	097	0	1	01	01	H5425_097_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																								
H5425	097	0	1	01	01	H5425_097_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																								
H5425	097	0	1	01	01	H5425_097_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											106.53	25	25	25				106.53	24	24	24										25	25	25				24	24	24			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
H5425	097	0	1	01	01	H5425_097_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											86.12	45	45	45				86.12	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
H5425	097	0	1	01	01	H5425_097_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																								
H5425	098	0	1	01	01	H5425_098_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																								
H5425	098	0	1	01	01	H5425_098_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																								
H5425	098	0	1	01	01	H5425_098_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											106.53	25	25	25				106.53	24	24	24										25	25	25				24	24	24			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
H5425	098	0	1	01	01	H5425_098_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											86.12	45	45	45				86.12	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
H5425	098	0	1	01	01	H5425_098_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																								
H5425	100	0	1	01	01	H5425_100_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	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																								
H5425	100	0	1	01	01	H5425_100_0	9			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																								
H5425	100	0	1	01	01	H5425_100_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	100	0	1	01	01	H5425_100_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											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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5425	100	0	1	01	01	H5425_100_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																								
H5425	101	0	1	01	01	H5425_101_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	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																								
H5425	101	0	1	01	01	H5425_101_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	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																								
H5425	101	0	1	01	01	H5425_101_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	101	0	1	01	01	H5425_101_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											79.22	50	50	50				79.22	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	105.00	35.00		35.00
H5425	101	0	1	01	01	H5425_101_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																								
H5425	102	0	1	01	01	H5425_102_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																								
H5425	102	0	1	01	01	H5425_102_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	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																								
H5425	102	0	1	01	01	H5425_102_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	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										0.00	0.00	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.30	50	50	50				82.30	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
H5425	102	0	1	01	01	H5425_102_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																								
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																								
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																								
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								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										0.00	0.00	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	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											93.29	50	50	50				93.29	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
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																								
H5425	105	0	1	01	01	H5425_105_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																								
H5425	105	0	1	01	01	H5425_105_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																								
H5425	105	0	1	01	01	H5425_105_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	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										0.00	0.00	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											79.44	50	50	50				79.44	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
H5425	105	0	1	01	01	H5425_105_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																								
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																								
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																								
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								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										0.00	0.00	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	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.10	50	50	50				82.10	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
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																								
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																								
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																								
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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	107	0	1	01	01	H5425_107_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											78.96	50	50	50				78.96	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
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																								
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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	108	0	1	01	01	H5425_108_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											78.65	50	50	50				78.65	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
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					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	109	0	1	01	01	H5425_109_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											87.33	50	50	50				87.33	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
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					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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								43.00	86.00	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	110	0	1	01	01	H5425_110_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											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										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
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					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5425	118	0	1	01	01	H5425_118_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																								
H5425	118	0	1	01	01	H5425_118_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																								
H5425	118	0	1	01	01	H5425_118_0	9			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	118	0	1	01	01	H5425_118_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											78.63	50	50	50				78.63	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
H5425	118	0	1	01	01	H5425_118_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																								
H5425	119	0	1	01	01	H5425_119_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																								
H5425	119	0	1	01	01	H5425_119_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																								
H5425	119	0	1	01	01	H5425_119_0	8			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	119	0	1	01	01	H5425_119_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											78.63	50	50	50				78.63	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
H5425	119	0	1	01	01	H5425_119_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																								
H5425	120	0	1	01	01	H5425_120_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																								
H5425	120	0	1	01	01	H5425_120_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																								
H5425	120	0	1	01	01	H5425_120_0	8			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	120	0	1	01	01	H5425_120_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											78.65	50	50	50				78.65	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
H5425	120	0	1	01	01	H5425_120_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																								
H5425	121	0	1	01	01	H5425_121_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																								
H5425	121	0	1	01	01	H5425_121_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																								
H5425	121	0	1	01	01	H5425_121_0	8			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	121	0	1	01	01	H5425_121_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											78.68	50	50	50				78.68	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
H5425	121	0	1	01	01	H5425_121_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																								
H5425	122	0	1	01	01	H5425_122_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																								
H5425	122	0	1	01	01	H5425_122_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																								
H5425	122	0	1	01	01	H5425_122_0	9			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	122	0	1	01	01	H5425_122_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											78.63	50	50	50				78.63	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
H5425	122	0	1	01	01	H5425_122_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																								
H5425	123	0	1	01	01	H5425_123_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																								
H5425	123	0	1	01	01	H5425_123_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																								
H5425	123	0	1	01	01	H5425_123_0	7			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H5425	123	0	1	01	01	H5425_123_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											78.65	50	50	50				78.65	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
H5425	123	0	1	01	01	H5425_123_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																								
H5427	059	0	1	01	01	H5427_059_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			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	0.00	0.00	0.00				0.00		0.00
H5427	059	0	1	01	01	H5427_059_0	7			Preferred Brand	4	11	3	2	2	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	94.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred 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
H5427	059	0	1	01	01	H5427_059_0	7			Non-Preferred Drug	4	11	3	2	3	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, Preferred Brand, Non-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
H5427	059	0	1	01	01	H5427_059_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	060	0	1	01	01	H5427_060_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			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	0.00	0.00	0.00				0.00		0.00
H5427	060	0	1	01	01	H5427_060_0	7			Preferred Brand	4	11	3	2	2	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	94.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred 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
H5427	060	0	1	01	01	H5427_060_0	7			Non-Preferred Drug	4	11	3	2	3	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, Preferred Brand, Non-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
H5427	060	0	1	01	01	H5427_060_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	070	0	1	01	01	H5427_070_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			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	0.00	0.00	0.00				0.00		0.00
H5427	070	0	1	01	01	H5427_070_0	7			Preferred Brand	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	10.00	10.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5427	070	0	1	01	01	H5427_070_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								55.00	110.00	165.00					50.00	100.00	150.00					50.00	100.00	100.00																55.00				55.00			1.83	1.67	1.67			1.62	Preferred 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	100.00				35.00		35.00
H5427	070	0	1	01	01	H5427_070_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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	7			Select Diabetic Drugs	4	11	1	2	5	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, 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				0.00		0.00
H5427	072	0	1	01	01	H5427_072_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			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	0.00	0.00	0.00				0.00		0.00
H5427	072	0	1	01	01	H5427_072_0	8			Preferred Brand	4	11	3	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	40.00	40.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5427	072	0	1	01	01	H5427_072_0	8			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								65.00	130.00	195.00					60.00	120.00	180.00					60.00	120.00	120.00																65.00				65.00			2.17	2.00	2.00			1.91	Preferred 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		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			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		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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5427	077	0	1	01	01	H5427_077_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			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	0.00	0.00	0.00				0.00		0.00
H5427	077	0	1	01	01	H5427_077_0	7			Preferred Brand	4	11	3	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	40.00	40.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	40.00				20.00		20.00
H5427	077	0	1	01	01	H5427_077_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								65.00	130.00	195.00					60.00	120.00	180.00					60.00	120.00	120.00																65.00				65.00			2.17	2.00	2.00			1.91	Preferred Generic, Preferred Brand, Non-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
H5427	077	0	1	01	01	H5427_077_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	078	0	1	01	01	H5427_078_0	8		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				2.56	24	24	24																		24	24	24															24			24								Preferred 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
H5427	078	0	1	01	01	H5427_078_0	8		N	Preferred Brand	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.40	25	25	25																		25	25	25															25			25								Preferred 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
H5427	078	0	1	01	01	H5427_078_0	8		N	Non-Preferred Drug	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				90.67	25	25	25																		25	25	25															25			25								Preferred 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
H5427	078	0	1	01	01	H5427_078_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, Supplemental Drugs																								
H5427	078	0	1	01	01	H5427_078_0	8		N	Supplemental Drugs	4	11	2	2	5	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5427	082	0	1	01	01	H5427_082_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			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	0.00	0.00	0.00				0.00		0.00
H5427	082	0	1	01	01	H5427_082_0	8			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5427	082	0	1	01	01	H5427_082_0	8			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								85.00	170.00	255.00					80.00	160.00	240.00					80.00	160.00	160.00																85.00				85.00			2.83	2.67	2.67			2.50	Preferred 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		35.00
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			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		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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5427	083	0	1	01	01	H5427_083_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			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	0.00	0.00	0.00				0.00		0.00
H5427	083	0	1	01	01	H5427_083_0	7			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H5427	083	0	1	01	01	H5427_083_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								85.00	170.00	255.00					80.00	160.00	240.00					80.00	160.00	160.00																85.00				85.00			2.83	2.67	2.67			2.50	Preferred Generic, Preferred Brand, Non-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
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			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	087	0	1	01	01	H5427_087_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				2.53	24	24	24																		24	24	24															24			24								Preferred 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
H5427	087	0	1	01	01	H5427_087_0	6		N	Preferred Brand	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.67	25	25	25																		25	25	25															25			25								Preferred 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
H5427	087	0	1	01	01	H5427_087_0	6		N	Non-Preferred Drug	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				85.09	25	25	25																		25	25	25															25			25								Preferred 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
H5427	087	0	1	01	01	H5427_087_0	6		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, Supplemental Drugs																								
H5427	087	0	1	01	01	H5427_087_0	6		N	Supplemental Drugs	4	11	2	2	5	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5427	088	0	1	01	01	H5427_088_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			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	0.00	0.00	0.00				0.00		0.00
H5427	088	0	1	01	01	H5427_088_0	7			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H5427	088	0	1	01	01	H5427_088_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								80.00	160.00	240.00					75.00	150.00	225.00					75.00	150.00	150.00																80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Preferred Brand, Non-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
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			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	089	0	1	01	01	H5427_089_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			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	0.00	0.00	0.00				0.00		0.00
H5427	089	0	1	01	01	H5427_089_0	8			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H5427	089	0	1	01	01	H5427_089_0	8			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								80.00	160.00	240.00					75.00	150.00	225.00					75.00	150.00	150.00																80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Preferred Brand, Non-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
H5427	089	0	1	01	01	H5427_089_0	8			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	091	0	1	01	01	H5427_091_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			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	0.00	0.00	0.00				0.00		0.00
H5427	091	0	1	01	01	H5427_091_0	8			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H5427	091	0	1	01	01	H5427_091_0	8			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								80.00	160.00	240.00					75.00	150.00	225.00					75.00	150.00	150.00																80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Preferred Brand, Non-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
H5427	091	0	1	01	01	H5427_091_0	8			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	092	0	1	01	01	H5427_092_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			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	0.00	0.00	0.00				0.00		0.00
H5427	092	0	1	01	01	H5427_092_0	7			Preferred Brand	4	11	3	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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5427	092	0	1	01	01	H5427_092_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								60.00	120.00	180.00					55.00	110.00	165.00					55.00	110.00	110.00																60.00				60.00			2.00	1.83	1.83			1.76	Preferred Generic, Preferred Brand, Non-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
H5427	092	0	1	01	01	H5427_092_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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		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, 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
H5427	093	0	1	01	01	H5427_093_0	7			Preferred Brand	4	11	3	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	30.00	30.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	30.00	45.00	15.00	30.00	45.00	15.00	30.00	30.00				15.00		15.00
H5427	093	0	1	01	01	H5427_093_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								65.00	130.00	195.00					60.00	120.00	180.00					60.00	120.00	120.00																65.00				65.00			2.17	2.00	2.00			1.91	Preferred Generic, Preferred Brand, Non-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
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			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		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, 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
H5427	094	0	1	01	01	H5427_094_0	7			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier										30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H5427	094	0	1	01	01	H5427_094_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								80.00	160.00	240.00					75.00	150.00	225.00					75.00	150.00	150.00																80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Preferred Brand, Non-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
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			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		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, 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
H5427	096	0	1	01	01	H5427_096_0	7			Preferred Brand	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	10.00	10.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										5.00	10.00	15.00	5.00	10.00	15.00	5.00	10.00	10.00				5.00		5.00
H5427	096	0	1	01	01	H5427_096_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								25.00	50.00	75.00					20.00	40.00	60.00					20.00	40.00	40.00																25.00				25.00			0.83	0.67	0.67			0.74	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00	50.00	75.00	20.00	40.00	60.00	20.00	40.00	40.00				25.00		25.00
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												30							30						30																	30			30								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		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, 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
H5427	098	0	1	01	01	H5427_098_0	7			Preferred Brand	4	11	3	2	2	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, 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
H5427	098	0	1	01	01	H5427_098_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Preferred Brand, Non-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
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			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	099	0	1	01	01	H5427_099_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			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	0.00	0.00	0.00				0.00		0.00
H5427	099	0	1	01	01	H5427_099_0	8			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5427	099	0	1	01	01	H5427_099_0	8			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								70.00	140.00	210.00					65.00	130.00	195.00					65.00	130.00	130.00																70.00				70.00			2.33	2.17	2.17			2.06	Preferred 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		35.00
H5427	099	0	1	01	01	H5427_099_0	8			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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	8			Select Diabetic Drugs	4	11	1	2	5	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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5427	102	0	1	01	01	H5427_102_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			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	0.00	0.00	0.00				0.00		0.00
H5427	102	0	1	01	01	H5427_102_0	7			Preferred Brand	4	11	3	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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5427	102	0	1	01	01	H5427_102_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Preferred Brand, Non-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
H5427	102	0	1	01	01	H5427_102_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	103	0	1	01	01	H5427_103_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			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	0.00	0.00	0.00				0.00		0.00
H5427	103	0	1	01	01	H5427_103_0	7			Preferred Brand	4	11	3	2	2	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, 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
H5427	103	0	1	01	01	H5427_103_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Preferred Brand, Non-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
H5427	103	0	1	01	01	H5427_103_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	105	0	1	01	01	H5427_105_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			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	0.00	0.00	0.00				0.00		0.00
H5427	105	0	1	01	01	H5427_105_0	7			Preferred Brand	4	11	3	2	2	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, 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
H5427	105	0	1	01	01	H5427_105_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Preferred Brand, Non-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
H5427	105	0	1	01	01	H5427_105_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	106	0	1	01	01	H5427_106_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			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	0.00	0.00	0.00				0.00		0.00
H5427	106	0	1	01	01	H5427_106_0	7			Preferred Brand	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	10.00	10.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										5.00	10.00	15.00	5.00	10.00	15.00	5.00	10.00	10.00				5.00		5.00
H5427	106	0	1	01	01	H5427_106_0	7			Non-Preferred Drug	4	11	3	2	3	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	20.00	20.00																15.00				15.00			0.50	0.33	0.33			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	30.00	45.00	10.00	20.00	30.00	10.00	20.00	20.00				15.00		15.00
H5427	106	0	1	01	01	H5427_106_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	107	0	1	01	01	H5427_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			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	0.00	0.00	0.00				0.00		0.00
H5427	107	0	1	01	01	H5427_107_0	8			Preferred Brand	4	11	3	2	2	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, 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
H5427	107	0	1	01	01	H5427_107_0	8			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								70.00	140.00	210.00					65.00	130.00	195.00					65.00	130.00	130.00																70.00				70.00			2.33	2.17	2.17			2.06	Preferred Generic, Preferred Brand, Non-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
H5427	107	0	1	01	01	H5427_107_0	8			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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		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, 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				0.00		0.00
H5427	108	0	1	01	01	H5427_108_0	6			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5427	108	0	1	01	01	H5427_108_0	6			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								85.00	170.00	255.00					80.00	160.00	240.00					80.00	160.00	160.00																85.00				85.00			2.83	2.67	2.67			2.50	Preferred 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		35.00
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			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	11	1	2	5	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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5427	112	0	1	02	01	H5427_112_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			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	0.00	0.00	0.00				0.00		0.00
H5427	112	0	1	02	01	H5427_112_0	7			Preferred Brand	4	11	3	2	2	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, 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
H5427	112	0	1	02	01	H5427_112_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Preferred Brand, Non-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
H5427	112	0	1	02	01	H5427_112_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5427	113	0	1	02	01	H5427_113_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			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	0.00	0.00	0.00				0.00		0.00
H5427	113	0	1	02	01	H5427_113_0	7			Preferred Brand	4	11	3	2	2	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, 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
H5427	113	0	1	02	01	H5427_113_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								75.00	150.00	225.00					70.00	140.00	210.00					70.00	140.00	140.00																75.00				75.00			2.50	2.33	2.33			2.21	Preferred Generic, Preferred Brand, Non-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
H5427	113	0	1	02	01	H5427_113_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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 Drug, Specialty Tier, Supplemental Drugs																								
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 Drug, Specialty Tier, Supplemental Drugs																								
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 Drug, Specialty Tier, Supplemental Drugs										0.00			0.00			0.00						0.00		0.00
H5431	001	0	1	01	01	H5431_001_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			30.00			30.00						35.00		35.00
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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	006	0	1	01	01	H5431_006_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5431	006	0	1	01	01	H5431_006_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5431	006	0	1	01	01	H5431_006_0	6			Preferred Brand	4	11	1	2	3	1	010		01	010		1	30								30						30		34	25.00																					25.00																		25.00				25.00		0.83			0.83			0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										25.00						25.00						25.00		25.00
H5431	006	0	1	01	01	H5431_006_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				97.03	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
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 Drug, 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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
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 Drug, Specialty Tier, Supplemental Drugs																								
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							5.00							5.00																		20.00				20.00			0.67	0.17	0.17			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										5.00			5.00			5.00						5.00		5.00
H5431	012	0	1	01	01	H5431_012_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			30.00			30.00						35.00		35.00
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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	013	0	1	01	01	H5431_013_0	8			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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	013	0	1	01	01	H5431_013_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, Supplemental Drugs																								
H5431	013	0	1	01	01	H5431_013_0	8			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 Drug, Specialty Tier, Supplemental Drugs										15.00			15.00			15.00						15.00		15.00
H5431	013	0	1	01	01	H5431_013_0	8			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			30.00			30.00						35.00		35.00
H5431	013	0	1	01	01	H5431_013_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, Supplemental Drugs																								
H5431	013	0	1	01	01	H5431_013_0	8			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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	016	0	1	01	01	H5431_016_0	6		N	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5431	016	0	1	01	01	H5431_016_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, Supplemental Drugs																								
H5431	016	0	1	01	01	H5431_016_0	6		N	Preferred Brand	4	11	1	2	3	1	010		01	010		1	30								30						30		34	1.00																					1.00																		1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1.00						1.00						1.00		1.00
H5431	016	0	1	01	01	H5431_016_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				72.20	20																				20																	20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	017	0	1	01	01	H5431_017_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	017	0	1	01	01	H5431_017_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, Supplemental Drugs																								
H5431	017	0	1	01	01	H5431_017_0	7			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								10.00							10.00							10.00																		10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										10.00			10.00			10.00						10.00		10.00
H5431	017	0	1	01	01	H5431_017_0	7			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			30.00			30.00						35.00		35.00
H5431	017	0	1	01	01	H5431_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, Supplemental Drugs																								
H5431	017	0	1	01	01	H5431_017_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	018	0	1	01	01	H5431_018_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	018	0	1	01	01	H5431_018_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, Supplemental Drugs																								
H5431	018	0	1	01	01	H5431_018_0	7			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								5.00							5.00							5.00																		5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										5.00			5.00			5.00						5.00		5.00
H5431	018	0	1	01	01	H5431_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								55.00							50.00							50.00																		55.00				55.00			1.83	1.67	1.67			1.62	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5431	018	0	1	01	01	H5431_018_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, Supplemental Drugs																								
H5431	018	0	1	01	01	H5431_018_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	019	0	1	01	01	H5431_019_0	8		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	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, Supplemental Drugs																								
H5431	019	0	1	01	01	H5431_019_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	019	0	1	01	01	H5431_019_0	8		N	Preferred Brand	4	11	1	2	3	1	010		01	010		1	30								30						30		34	25.00																					25.00																		25.00				25.00		0.83			0.83			0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										25.00						25.00						25.00		25.00
H5431	019	0	1	01	01	H5431_019_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				93.01	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5431	019	0	1	01	01	H5431_019_0	8		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, Supplemental Drugs																								
H5431	019	0	1	01	01	H5431_019_0	8		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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
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 Drug, Specialty Tier, Supplemental Drugs																								
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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5431	020	0	1	01	01	H5431_020_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	021	0	1	01	01	H5431_021_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5431	021	0	1	01	01	H5431_021_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, Supplemental Drugs																								
H5431	021	0	1	01	01	H5431_021_0	7			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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5431	021	0	1	01	01	H5431_021_0	7			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5431	021	0	1	01	01	H5431_021_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, Supplemental Drugs																								
H5431	021	0	1	01	01	H5431_021_0	7			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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
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 Drug, Specialty Tier, Supplemental Drugs																								
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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5431	022	0	1	01	01	H5431_022_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
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 Drug, 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 Drug, Specialty Tier, Supplemental Drugs																								
H5433	003	0	1	01	01	H5433_003_0	12		N	Generic	4	01	3	1	1	1	111		01			1	30	60	100				1	2							30		31				3.71	23	23	23																																			23			23								Generic, Brand										35.00	70.00	105.00										35.00		35.00
H5433	003	0	1	01	01	H5433_003_0	12		N	Brand	4	10	1	1	2	1	111		01			1	30	60	100				1	2							30		31				120.36	25	25	25																																			25			25								Generic, Brand										35.00	70.00	105.00										35.00		35.00
H5434	002	0	1	04	01	H5434_002_0	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				53.45	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				44.38	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				135.32	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				46.86	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				33.12	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				139.34	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				52.21	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				31.44	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				156.00	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				47.71	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				26.69	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				153.03	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				51.33	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				34.74	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				140.97	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				52.01	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				32.95	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				127.25	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				47.35	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				29.40	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				124.24	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				49.25	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				28.17	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				136.23	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				48.85	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				30.38	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				152.35	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	8			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	8			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	8			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	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				50.21	25		25																		25		25															25			25								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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				36.11	25		25																		25		25															25			25								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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				146.83	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	8			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	045	0	1	04	01	H5434_045_0	8			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	045	0	1	04	01	H5434_045_0	8			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	045	0	1	04	01	H5434_045_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				29.02	21		21																		21		21															21			21								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	045	0	1	04	01	H5434_045_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				22.09	25		25																		25		25															25			25								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	045	0	1	04	01	H5434_045_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				315.17	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
H5434	045	0	1	04	01	H5434_045_0	8			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																								
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	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				166.00	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
H5439	011	0	1	04	01	H5439_011_0	5			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	011	0	1	04	01	H5439_011_0	5			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																								
H5439	011	0	1	04	01	H5439_011_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											147.28	25	25	25				147.28	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
H5439	011	0	1	04	01	H5439_011_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											73.38	44	44	44				73.38	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
H5439	011	0	1	04	01	H5439_011_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, Select Care Drugs																								
H5439	011	0	1	04	01	H5439_011_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																								
H5439	015	0	1	04	01	H5439_015_0	5			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	015	0	1	04	01	H5439_015_0	5			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																								
H5439	015	0	1	04	01	H5439_015_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.78	25	25	25				151.78	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
H5439	015	0	1	04	01	H5439_015_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											67.29	43	43	43				67.29	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
H5439	015	0	1	04	01	H5439_015_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, Select Care Drugs																								
H5439	015	0	1	04	01	H5439_015_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																								
H5439	017	0	1	04	01	H5439_017_0	5			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	5			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																								
H5439	017	0	1	04	01	H5439_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											160.82	25	25	25				160.82	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
H5439	017	0	1	04	01	H5439_017_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											62.96	36	36	36				62.96	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
H5439	017	0	1	04	01	H5439_017_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, Select Care Drugs																								
H5439	017	0	1	04	01	H5439_017_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																								
H5439	019	0	1	04	01	H5439_019_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																								
H5439	019	0	1	04	01	H5439_019_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H5439	019	0	1	04	01	H5439_019_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											150.09	25	25	25				150.09	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
H5439	019	0	1	04	01	H5439_019_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											59.62	39	39	39				59.62	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
H5439	019	0	1	04	01	H5439_019_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, Select Care Drugs																								
H5439	019	0	1	04	01	H5439_019_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																								
H5447	001	0	1	01	01	H5447_001_0	5			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	5			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										7.00	14.00	17.50				7.00	14.00	17.50				7.00		7.00
H5447	001	0	1	01	01	H5447_001_0	5			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	5			Non-Preferred Brand	4	10	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				133.78	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	001	0	1	01	01	H5447_001_0	5			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1078.04	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				5.04	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				31.12	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	Preferred Brand	3	10	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				127.14	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				132.54	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	Specialty Tier	3	11	1	1	5	1	010		10	010		1	30								30							29	31				756.45	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H5453	001	0	1	04	01	H5453_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5453	001	0	1	04	01	H5453_001_0	7			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
H5453	001	0	1	04	01	H5453_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H5453	001	0	1	04	01	H5453_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				46.00	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
H5453	001	0	1	04	01	H5453_001_0	7			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
H5453	002	0	1	04	01	H5453_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5453	002	0	1	04	01	H5453_002_0	7			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
H5453	002	0	1	04	01	H5453_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				58.00	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
H5453	002	0	1	04	01	H5453_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				46.00	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
H5453	002	0	1	04	01	H5453_002_0	7			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
H5453	004	0	1	04	01	H5453_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5453	004	0	1	04	01	H5453_004_0	7			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
H5453	004	0	1	04	01	H5453_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H5453	004	0	1	04	01	H5453_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				46.00	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
H5453	004	0	1	04	01	H5453_004_0	7			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
H5453	005	0	1	04	01	H5453_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5453	005	0	1	04	01	H5453_005_0	7			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
H5453	005	0	1	04	01	H5453_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H5453	005	0	1	04	01	H5453_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				46.00	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
H5453	005	0	1	04	01	H5453_005_0	7			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
H5453	010	0	1	04	01	H5453_010_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5453	010	0	1	04	01	H5453_010_0	7			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
H5453	010	0	1	04	01	H5453_010_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H5453	010	0	1	04	01	H5453_010_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				46.00	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
H5453	010	0	1	04	01	H5453_010_0	7			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
H5453	011	0	1	04	01	H5453_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5453	011	0	1	04	01	H5453_011_0	7			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
H5453	011	0	1	04	01	H5453_011_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H5453	011	0	1	04	01	H5453_011_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				46.00	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
H5453	011	0	1	04	01	H5453_011_0	7			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
H5454	001	0	1	01	01	H5454_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	8			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	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	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	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
H5454	001	0	1	01	01	H5454_001_0	8			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	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																								
H5454	005	0	1	01	01	H5454_005_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	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	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
H5454	005	0	1	01	01	H5454_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
H5454	005	0	1	01	01	H5454_005_0	9			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				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	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	8		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				1.56	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	064	0	1	01	01	H5471_064_0	8		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.24	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	064	0	1	01	01	H5471_064_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				102.69	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
H5471	064	0	1	01	01	H5471_064_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				115.33	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	064	0	1	01	01	H5471_064_0	8		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, Supplemental Drugs																								
H5471	064	0	1	01	01	H5471_064_0	8		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	065	0	1	01	01	H5471_065_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	065	0	1	01	01	H5471_065_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, Supplemental Drugs																								
H5471	065	0	1	01	01	H5471_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	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	0.00				0.00		0.00
H5471	065	0	1	01	01	H5471_065_0	7			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			30.00			30.00						35.00		35.00
H5471	065	0	1	01	01	H5471_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, Supplemental Drugs																								
H5471	065	0	1	01	01	H5471_065_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	066	0	1	01	01	H5471_066_0	7		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	3.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	066	0	1	01	01	H5471_066_0	7		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	3.00	6.00	9.00																			3.00	9.00	9.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	066	0	1	01	01	H5471_066_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				63.28	14	14	14																		14	14	14															14			14								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
H5471	066	0	1	01	01	H5471_066_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				121.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	066	0	1	01	01	H5471_066_0	7		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, Supplemental Drugs																								
H5471	066	0	1	01	01	H5471_066_0	7		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	068	0	1	01	01	H5471_068_0	6			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	068	0	1	01	01	H5471_068_0	6			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	068	0	1	01	01	H5471_068_0	6			Preferred Brand	4	11	1	1	3	1	111		01			1	30	60	90				2	2							30		34				82.77	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		35.00
H5471	068	0	1	01	01	H5471_068_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01			1	30														30		34				98.33	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00												35.00		35.00
H5471	068	0	1	01	01	H5471_068_0	6			Specialty Tier	4	11	1	1	5	1	010		01			1	30														30		34					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	068	0	1	01	01	H5471_068_0	6			Supplemental Drugs	4	01	2	2	6	1	111		01			1	30	60	90				1	2							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, Supplemental Drugs																								
H5471	069	0	1	01	01	H5471_069_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	069	0	1	01	01	H5471_069_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, Supplemental Drugs																								
H5471	069	0	1	01	01	H5471_069_0	6			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			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	0.00				0.00		0.00
H5471	069	0	1	01	01	H5471_069_0	6			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								30.00							25.00							25.00																		30.00				30.00			1.00	0.83	0.83			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										30.00			25.00			25.00						30.00		30.00
H5471	069	0	1	01	01	H5471_069_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, Supplemental Drugs																								
H5471	069	0	1	01	01	H5471_069_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	070	0	1	01	01	H5471_070_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	070	0	1	01	01	H5471_070_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, Supplemental Drugs																								
H5471	070	0	1	01	01	H5471_070_0	7			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	30.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										15.00	30.00	45.00	15.00	30.00	45.00	15.00	30.00	45.00				15.00		15.00
H5471	070	0	1	01	01	H5471_070_0	7			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								60.00							55.00							55.00																		60.00				60.00			2.00	1.83	1.83			1.76	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	070	0	1	01	01	H5471_070_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, Supplemental Drugs																								
H5471	070	0	1	01	01	H5471_070_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	071	0	1	01	01	H5471_071_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	071	0	1	01	01	H5471_071_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, Supplemental Drugs																								
H5471	071	0	1	01	01	H5471_071_0	6			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	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, Supplemental Drugs										10.00	20.00	30.00	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	6			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								60.00							55.00							55.00																		60.00				60.00			2.00	1.83	1.83			1.76	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	071	0	1	01	01	H5471_071_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, Supplemental Drugs																								
H5471	071	0	1	01	01	H5471_071_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	072	0	1	01	01	H5471_072_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				1.67	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	072	0	1	01	01	H5471_072_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.31	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	072	0	1	01	01	H5471_072_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				133.85	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
H5471	072	0	1	01	01	H5471_072_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				115.13	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	072	0	1	01	01	H5471_072_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, Supplemental Drugs																								
H5471	072	0	1	01	01	H5471_072_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	073	0	1	01	01	H5471_073_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	073	0	1	01	01	H5471_073_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, Supplemental Drugs																								
H5471	073	0	1	01	01	H5471_073_0	7			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	90.00																30.00				30.00			1.00	1.00	1.00			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	90.00				30.00		30.00
H5471	073	0	1	01	01	H5471_073_0	7			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								80.00							75.00							75.00																		80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	073	0	1	01	01	H5471_073_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, Supplemental Drugs																								
H5471	073	0	1	01	01	H5471_073_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	074	0	1	01	01	H5471_074_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	074	0	1	01	01	H5471_074_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, Supplemental Drugs																								
H5471	074	0	1	01	01	H5471_074_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	105.00	105.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	074	0	1	01	01	H5471_074_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	074	0	1	01	01	H5471_074_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, Supplemental Drugs																								
H5471	074	0	1	01	01	H5471_074_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	075	0	1	01	01	H5471_075_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	075	0	1	01	01	H5471_075_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, Supplemental Drugs																								
H5471	075	0	1	01	01	H5471_075_0	6			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	90.00																30.00				30.00			1.00	1.00	1.00			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										30.00	60.00	90.00	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	6			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								80.00							75.00							75.00																		80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	075	0	1	01	01	H5471_075_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, Supplemental Drugs																								
H5471	075	0	1	01	01	H5471_075_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	076	0	1	01	01	H5471_076_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				1.67	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	076	0	1	01	01	H5471_076_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.38	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	076	0	1	01	01	H5471_076_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				115.62	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
H5471	076	0	1	01	01	H5471_076_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				109.08	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	076	0	1	01	01	H5471_076_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, Supplemental Drugs																								
H5471	076	0	1	01	01	H5471_076_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	077	0	1	01	01	H5471_077_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	077	0	1	01	01	H5471_077_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, Supplemental Drugs																								
H5471	077	0	1	01	01	H5471_077_0	6			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	75.00	75.00																25.00				25.00			0.83	0.83	0.83			0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										25.00	50.00	75.00	25.00	50.00	75.00	25.00	50.00	75.00				25.00		25.00
H5471	077	0	1	01	01	H5471_077_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	077	0	1	01	01	H5471_077_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, Supplemental Drugs																								
H5471	077	0	1	01	01	H5471_077_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	078	0	1	01	01	H5471_078_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	078	0	1	01	01	H5471_078_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, Supplemental Drugs																								
H5471	078	0	1	01	01	H5471_078_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	105.00	105.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	078	0	1	01	01	H5471_078_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, Supplemental Drugs																								
H5471	078	0	1	01	01	H5471_078_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	080	0	1	01	01	H5471_080_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	080	0	1	01	01	H5471_080_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, Supplemental Drugs																								
H5471	080	0	1	01	01	H5471_080_0	6			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	30.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										15.00	30.00	45.00	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	6			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								80.00							75.00							75.00																		80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	080	0	1	01	01	H5471_080_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, Supplemental Drugs																								
H5471	080	0	1	01	01	H5471_080_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	082	0	1	01	01	H5471_082_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				1.73	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	082	0	1	01	01	H5471_082_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.81	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	082	0	1	01	01	H5471_082_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				127.43	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
H5471	082	0	1	01	01	H5471_082_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				117.93	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	082	0	1	01	01	H5471_082_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, Supplemental Drugs																								
H5471	082	0	1	01	01	H5471_082_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	083	0	1	01	01	H5471_083_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	083	0	1	01	01	H5471_083_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, Supplemental Drugs																								
H5471	083	0	1	01	01	H5471_083_0	6			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	75.00	75.00																25.00				25.00			0.83	0.83	0.83			0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										25.00	50.00	75.00	25.00	50.00	75.00	25.00	50.00	75.00				25.00		25.00
H5471	083	0	1	01	01	H5471_083_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	083	0	1	01	01	H5471_083_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, Supplemental Drugs																								
H5471	083	0	1	01	01	H5471_083_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	084	0	1	01	01	H5471_084_0	7		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				1.94	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	084	0	1	01	01	H5471_084_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.12	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	084	0	1	01	01	H5471_084_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				126.74	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
H5471	084	0	1	01	01	H5471_084_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				139.02	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	084	0	1	01	01	H5471_084_0	7		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, Supplemental Drugs																								
H5471	084	0	1	01	01	H5471_084_0	7		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	085	0	1	01	01	H5471_085_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	085	0	1	01	01	H5471_085_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, Supplemental Drugs																								
H5471	085	0	1	01	01	H5471_085_0	6			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	30.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										15.00	30.00	45.00	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	6			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								80.00							75.00							75.00																		80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	085	0	1	01	01	H5471_085_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, Supplemental Drugs																								
H5471	085	0	1	01	01	H5471_085_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	103	0	1	01	01	H5471_103_0	5			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	103	0	1	01	01	H5471_103_0	5			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, Supplemental Drugs																								
H5471	103	0	1	01	01	H5471_103_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	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, Supplemental Drugs										35.00	70.00	105.00	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	5			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	103	0	1	01	01	H5471_103_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, Supplemental Drugs																								
H5471	103	0	1	01	01	H5471_103_0	5			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	104	0	1	01	01	H5471_104_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	104	0	1	01	01	H5471_104_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					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, Supplemental Drugs																								
H5471	104	0	1	01	01	H5471_104_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	104	0	1	01	01	H5471_104_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, Supplemental Drugs																								
H5471	104	0	1	01	01	H5471_104_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	105	0	1	01	01	H5471_105_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	105	0	1	01	01	H5471_105_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					0.00	0.00	0.00																15.00				15.00			0.50	0.50	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	105	0	1	01	01	H5471_105_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	105	0	1	01	01	H5471_105_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, Supplemental Drugs																								
H5471	105	0	1	01	01	H5471_105_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	106	0	1	01	01	H5471_106_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	106	0	1	01	01	H5471_106_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					20.00	40.00	60.00					0.00	0.00	0.00																20.00				20.00			0.67	0.67	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	106	0	1	01	01	H5471_106_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, Supplemental Drugs										35.00	70.00	105.00	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	7			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	106	0	1	01	01	H5471_106_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, Supplemental Drugs																								
H5471	106	0	1	01	01	H5471_106_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	107	0	1	01	01	H5471_107_0	5			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	107	0	1	01	01	H5471_107_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					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, Supplemental Drugs																								
H5471	107	0	1	01	01	H5471_107_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	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, Supplemental Drugs										35.00	70.00	105.00	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	5			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	107	0	1	01	01	H5471_107_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, Supplemental Drugs																								
H5471	107	0	1	01	01	H5471_107_0	5			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	108	0	1	01	01	H5471_108_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	108	0	1	01	01	H5471_108_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					20.00	40.00	60.00					0.00	0.00	0.00																20.00				20.00			0.67	0.67	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	108	0	1	01	01	H5471_108_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	108	0	1	01	01	H5471_108_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, Supplemental Drugs																								
H5471	108	0	1	01	01	H5471_108_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	110	0	1	01	01	H5471_110_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	110	0	1	01	01	H5471_110_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, Supplemental Drugs																								
H5471	110	0	1	01	01	H5471_110_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	105.00	105.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	110	0	1	01	01	H5471_110_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, Supplemental Drugs																								
H5471	110	0	1	01	01	H5471_110_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	111	0	1	01	01	H5471_111_0	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	3.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	111	0	1	01	01	H5471_111_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	3.00	6.00	9.00																			3.00	9.00	9.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	111	0	1	01	01	H5471_111_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				69.87	14	14	14																		14	14	14															14			14								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
H5471	111	0	1	01	01	H5471_111_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				134.60	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	111	0	1	01	01	H5471_111_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, Supplemental Drugs																								
H5471	111	0	1	01	01	H5471_111_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	112	0	1	01	01	H5471_112_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	112	0	1	01	01	H5471_112_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					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, Supplemental Drugs																								
H5471	112	0	1	01	01	H5471_112_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	112	0	1	01	01	H5471_112_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, Supplemental Drugs																								
H5471	112	0	1	01	01	H5471_112_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	113	0	1	01	01	H5471_113_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	113	0	1	01	01	H5471_113_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, Supplemental Drugs																								
H5471	113	0	1	01	01	H5471_113_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	113	0	1	01	01	H5471_113_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, Supplemental Drugs																								
H5471	113	0	1	01	01	H5471_113_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	114	0	1	01	01	H5471_114_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	114	0	1	01	01	H5471_114_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, Supplemental Drugs																								
H5471	114	0	1	01	01	H5471_114_0	6			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			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	0.00				0.00		0.00
H5471	114	0	1	01	01	H5471_114_0	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			30.00			30.00						35.00		35.00
H5471	114	0	1	01	01	H5471_114_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, Supplemental Drugs																								
H5471	114	0	1	01	01	H5471_114_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	115	0	1	01	01	H5471_115_0	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	3.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	115	0	1	01	01	H5471_115_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				4.99	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	115	0	1	01	01	H5471_115_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				139.86	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
H5471	115	0	1	01	01	H5471_115_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				151.05	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	115	0	1	01	01	H5471_115_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, Supplemental Drugs																								
H5471	115	0	1	01	01	H5471_115_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	116	0	1	01	01	H5471_116_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	116	0	1	01	01	H5471_116_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, Supplemental Drugs																								
H5471	116	0	1	01	01	H5471_116_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	116	0	1	01	01	H5471_116_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, Supplemental Drugs																								
H5471	116	0	1	01	01	H5471_116_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	117	0	1	01	01	H5471_117_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	117	0	1	01	01	H5471_117_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					20.00	40.00	60.00					0.00	0.00	0.00																20.00				20.00			0.67	0.67	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	117	0	1	01	01	H5471_117_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	117	0	1	01	01	H5471_117_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, Supplemental Drugs																								
H5471	117	0	1	01	01	H5471_117_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	118	0	1	01	01	H5471_118_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				1.84	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	118	0	1	01	01	H5471_118_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.33	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	118	0	1	01	01	H5471_118_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				122.93	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
H5471	118	0	1	01	01	H5471_118_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				132.27	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	118	0	1	01	01	H5471_118_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, Supplemental Drugs																								
H5471	118	0	1	01	01	H5471_118_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	119	0	1	01	01	H5471_119_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	119	0	1	01	01	H5471_119_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, Supplemental Drugs																								
H5471	119	0	1	01	01	H5471_119_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	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, Supplemental Drugs										35.00	70.00	105.00	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	7			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	119	0	1	01	01	H5471_119_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, Supplemental Drugs																								
H5471	119	0	1	01	01	H5471_119_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	120	0	1	01	01	H5471_120_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	120	0	1	01	01	H5471_120_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					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, Supplemental Drugs																								
H5471	120	0	1	01	01	H5471_120_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	120	0	1	01	01	H5471_120_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, Supplemental Drugs																								
H5471	120	0	1	01	01	H5471_120_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	121	0	1	01	01	H5471_121_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				1.84	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	121	0	1	01	01	H5471_121_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.34	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	121	0	1	01	01	H5471_121_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				123.27	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
H5471	121	0	1	01	01	H5471_121_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				133.01	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	121	0	1	01	01	H5471_121_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, Supplemental Drugs																								
H5471	121	0	1	01	01	H5471_121_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	122	0	1	01	01	H5471_122_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	122	0	1	01	01	H5471_122_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, Supplemental Drugs																								
H5471	122	0	1	01	01	H5471_122_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	122	0	1	01	01	H5471_122_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, Supplemental Drugs																								
H5471	122	0	1	01	01	H5471_122_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	123	0	1	01	01	H5471_123_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	123	0	1	01	01	H5471_123_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					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, Supplemental Drugs																								
H5471	123	0	1	01	01	H5471_123_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	123	0	1	01	01	H5471_123_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, Supplemental Drugs																								
H5471	123	0	1	01	01	H5471_123_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	124	0	1	01	01	H5471_124_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	124	0	1	01	01	H5471_124_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, Supplemental Drugs																								
H5471	124	0	1	01	01	H5471_124_0	6			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	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, Supplemental Drugs										15.00	30.00	45.00	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	6			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								80.00							75.00							75.00																		80.00				80.00			2.67	2.50	2.50			2.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	124	0	1	01	01	H5471_124_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, Supplemental Drugs																								
H5471	124	0	1	01	01	H5471_124_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	125	0	1	01	01	H5471_125_0	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	1.00	2.00	3.00																			1.00	3.00	3.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	125	0	1	01	01	H5471_125_0	6		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	12.00	12.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5471	125	0	1	01	01	H5471_125_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				107.34	19	19	19																		19	19	19															19			19								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
H5471	125	0	1	01	01	H5471_125_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				154.31	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00						35.00						35.00		35.00
H5471	125	0	1	01	01	H5471_125_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, Supplemental Drugs																								
H5471	125	0	1	01	01	H5471_125_0	6		N	Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5471	126	0	1	01	01	H5471_126_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 Drug, Specialty Tier, Supplemental Drugs																								
H5471	126	0	1	01	01	H5471_126_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, Supplemental Drugs																								
H5471	126	0	1	01	01	H5471_126_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, Supplemental Drugs										35.00	70.00	105.00	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	6			Non-Preferred Drug	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 Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H5471	126	0	1	01	01	H5471_126_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, Supplemental Drugs																								
H5471	126	0	1	01	01	H5471_126_0	6			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H5472	001	0	1	02	01	H5472_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, 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	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										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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				573.03	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	8			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	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
H5472	002	0	1	02	01	H5472_002_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										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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				541.38	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	8			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	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
H5472	003	0	1	02	01	H5472_003_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										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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				438.36	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	8			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	005	0	1	02	01	H5472_005_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
H5472	005	0	1	02	01	H5472_005_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5472	005	0	1	02	01	H5472_005_0	8			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	005	0	1	02	01	H5472_005_0	8			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	005	0	1	02	01	H5472_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				532.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5472	005	0	1	02	01	H5472_005_0	8			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																								
H5475	001	0	1	02	01	H5475_001_0	5		N	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5475	001	0	1	02	01	H5475_001_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5475	001	0	1	02	01	H5475_001_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											125.56	22	22	22				119.85	21	21	21										22	22	22				21	21	21			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
H5475	001	0	1	02	01	H5475_001_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											29.78	37	37	37				28.98	36	36	36										37	37	37				36	36	36			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
H5475	001	0	1	02	01	H5475_001_0	5		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, Select Care Drugs																								
H5475	001	0	1	02	01	H5475_001_0	5		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	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	024	0	1	02	01	H5475_024_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											161.05	25	25	25				161.05	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
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											38.98	36	36	36				38.98	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
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												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
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	5			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	026	0	1	02	01	H5475_026_0	5			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																								
H5475	026	0	1	02	01	H5475_026_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.50	25	25	25				154.50	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
H5475	026	0	1	02	01	H5475_026_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											42.17	45	45	45				41.24	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
H5475	026	0	1	02	01	H5475_026_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, Select Care Drugs																								
H5475	026	0	1	02	01	H5475_026_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																								
H5475	031	0	1	02	01	H5475_031_0	5			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	031	0	1	02	01	H5475_031_0	5			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																								
H5475	031	0	1	02	01	H5475_031_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											160.24	25	25	25				160.24	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
H5475	031	0	1	02	01	H5475_031_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											49.56	37	37	37				49.56	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
H5475	031	0	1	02	01	H5475_031_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, Select Care Drugs																								
H5475	031	0	1	02	01	H5475_031_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																								
H5475	038	0	1	02	01	H5475_038_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5475	038	0	1	02	01	H5475_038_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5475	038	0	1	02	01	H5475_038_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											135.26	22	22	22				135.26	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
H5475	038	0	1	02	01	H5475_038_0	5			Non-Preferred Drug	3	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	200.00				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
H5475	038	0	1	02	01	H5475_038_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																								
H5475	038	0	1	02	01	H5475_038_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								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	039	0	1	02	01	H5475_039_0	5		N	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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5475	039	0	1	02	01	H5475_039_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5475	039	0	1	02	01	H5475_039_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											147.43	23	23	23				141.02	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
H5475	039	0	1	02	01	H5475_039_0	5		N	Non-Preferred Drug	3	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	200.00				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
H5475	039	0	1	02	01	H5475_039_0	5		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, Select Care Drugs																								
H5475	039	0	1	02	01	H5475_039_0	5		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	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	8			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	8			Generic	4	11	3	2	2	1	110		01	100		1	30		100				1	2			100				30		31	6.00		5.00																					5.00																6.00				6.00		0.20						0.19	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	8			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	8			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										0.00		0.00						0.00				0.00		0.00
H5496	005	0	1	01	01	H5496_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1194.72	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	8			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	3.00		0.00																					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	8			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	8			Generic	4	11	3	2	2	1	110		01	100		1	30		100				1	2			100				30		31	10.00		10.00																					10.00																10.00				10.00		0.33						0.32	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	8			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	8			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										0.00		0.00						0.00				0.00		0.00
H5496	007	0	1	01	01	H5496_007_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				833.50	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5496	011	0	1	01	01	H5496_011_0	8		N	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	011	0	1	01	01	H5496_011_0	8		N	Generic	4	11	3	2	2	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										0.00		0.00						0.00				0.00		0.00
H5496	011	0	1	01	01	H5496_011_0	8		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				198.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H5496	011	0	1	01	01	H5496_011_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				101.76	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00		0.00						0.00				0.00		0.00
H5496	011	0	1	01	01	H5496_011_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				699.68	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5496	012	0	1	01	01	H5496_012_0	8			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	8			Generic	4	11	3	2	2	1	110		01	100		1	30		100				1	2			100				30		31	6.00		5.00																					5.00																6.00				6.00		0.20						0.19	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	8			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	012	0	1	01	01	H5496_012_0	8			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										0.00		0.00						0.00				0.00		0.00
H5496	012	0	1	01	01	H5496_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				929.54	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	013	0	1	04	01	H5521_013_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	013	0	1	04	01	H5521_013_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	013	0	1	04	01	H5521_013_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.18	24	24	24				106.17	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
H5521	013	0	1	04	01	H5521_013_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.20	25	25	25				42.20	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
H5521	013	0	1	04	01	H5521_013_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											807.93	25						852.30	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
H5521	015	0	1	04	01	H5521_015_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	015	0	1	04	01	H5521_015_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	015	0	1	04	01	H5521_015_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.21	25	25	25				111.07	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	015	0	1	04	01	H5521_015_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.01	26	26	26				42.05	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											855.22	30						854.25	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
H5521	016	0	1	04	01	H5521_016_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	016	0	1	04	01	H5521_016_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	016	0	1	04	01	H5521_016_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.36	24	24	24				111.88	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
H5521	016	0	1	04	01	H5521_016_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.75	25	25	25				45.67	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
H5521	016	0	1	04	01	H5521_016_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											744.40	25						873.50	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
H5521	020	0	1	04	01	H5521_020_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	020	0	1	04	01	H5521_020_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	020	0	1	04	01	H5521_020_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.42	25	25	25				82.51	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	020	0	1	04	01	H5521_020_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.04	35	35	35				33.23	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
H5521	020	0	1	04	01	H5521_020_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											952.85	33						1190.15	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
H5521	022	0	1	04	01	H5521_022_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	022	0	1	04	01	H5521_022_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	022	0	1	04	01	H5521_022_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.43	24	24	24				99.13	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
H5521	022	0	1	04	01	H5521_022_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.24	25	25	25				42.26	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	022	0	1	04	01	H5521_022_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											776.50	25						792.40	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
H5521	027	0	1	04	01	H5521_027_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	027	0	1	04	01	H5521_027_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	027	0	1	04	01	H5521_027_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.16	24	24	24				102.53	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
H5521	027	0	1	04	01	H5521_027_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.30	25	25	25				36.12	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	027	0	1	04	01	H5521_027_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											777.75	25						788.76	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
H5521	033	0	1	04	01	H5521_033_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	033	0	1	04	01	H5521_033_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	033	0	1	04	01	H5521_033_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.47	24	24	24				103.39	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
H5521	033	0	1	04	01	H5521_033_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.70	25	25	25				41.34	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	033	0	1	04	01	H5521_033_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											944.32	25						842.82	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
H5521	037	0	1	04	01	H5521_037_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	037	0	1	04	01	H5521_037_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	037	0	1	04	01	H5521_037_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.69	25	25	25				93.82	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
H5521	037	0	1	04	01	H5521_037_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.49	35	35	35				37.14	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
H5521	037	0	1	04	01	H5521_037_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											989.73	33						1260.50	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
H5521	040	0	1	04	01	H5521_040_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	040	0	1	04	01	H5521_040_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	040	0	1	04	01	H5521_040_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											97.72	24	24	24				111.20	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
H5521	040	0	1	04	01	H5521_040_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.08	25	25	25				49.04	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
H5521	040	0	1	04	01	H5521_040_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											842.63	25						705.54	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
H5521	055	0	1	04	01	H5521_055_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	055	0	1	04	01	H5521_055_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	055	0	1	04	01	H5521_055_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.86	24	24	24				101.26	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
H5521	055	0	1	04	01	H5521_055_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.76	25	25	25				39.52	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	055	0	1	04	01	H5521_055_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											523.14	25						682.03	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
H5521	077	0	1	04	01	H5521_077_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	077	0	1	04	01	H5521_077_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	077	0	1	04	01	H5521_077_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											99.97	24	24	24				114.66	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
H5521	077	0	1	04	01	H5521_077_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.21	25	25	25				37.40	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	077	0	1	04	01	H5521_077_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1010.05	25						895.23	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
H5521	081	0	1	04	01	H5521_081_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	081	0	1	04	01	H5521_081_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	081	0	1	04	01	H5521_081_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.67	25	25	25				111.28	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	081	0	1	04	01	H5521_081_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.47	26	26	26				34.52	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1107.17	30						1010.62	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	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	084	0	1	04	01	H5521_084_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	084	0	1	04	01	H5521_084_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.93	24	24	24				92.57	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
H5521	084	0	1	04	01	H5521_084_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											38.97	25	25	25				35.91	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	084	0	1	04	01	H5521_084_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											782.09	25						815.26	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
H5521	085	0	1	04	01	H5521_085_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	085	0	1	04	01	H5521_085_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	085	0	1	04	01	H5521_085_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.84	25	25	25				110.78	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	085	0	1	04	01	H5521_085_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.06	26	26	26				33.05	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											967.27	30						772.87	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	086	0	1	04	01	H5521_086_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	086	0	1	04	01	H5521_086_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	086	0	1	04	01	H5521_086_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											97.05	24	24	24				122.80	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
H5521	086	0	1	04	01	H5521_086_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.22	25	25	25				35.98	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
H5521	086	0	1	04	01	H5521_086_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											928.70	25						835.04	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
H5521	087	0	1	04	01	H5521_087_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	087	0	1	04	01	H5521_087_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	087	0	1	04	01	H5521_087_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.50	25	25	25				95.97	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	087	0	1	04	01	H5521_087_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.82	35	35	35				29.72	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
H5521	087	0	1	04	01	H5521_087_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											738.99	33						949.31	33												33						33						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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	088	0	1	04	01	H5521_088_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	088	0	1	04	01	H5521_088_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.04	25	25	25				119.32	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
H5521	088	0	1	04	01	H5521_088_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.91	26	26	26				32.15	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											938.15	30						942.85	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
H5521	089	0	1	04	01	H5521_089_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	089	0	1	04	01	H5521_089_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	089	0	1	04	01	H5521_089_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.37	24	24	24				114.98	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
H5521	089	0	1	04	01	H5521_089_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.36	25	25	25				35.03	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	089	0	1	04	01	H5521_089_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											755.41	25						741.42	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
H5521	091	0	1	04	01	H5521_091_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	091	0	1	04	01	H5521_091_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	091	0	1	04	01	H5521_091_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.39	24	24	24				112.78	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
H5521	091	0	1	04	01	H5521_091_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.56	25	25	25				37.96	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	091	0	1	04	01	H5521_091_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											976.99	25						845.39	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
H5521	095	0	1	04	01	H5521_095_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	095	0	1	04	01	H5521_095_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	095	0	1	04	01	H5521_095_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.36	24	24	24				106.69	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
H5521	095	0	1	04	01	H5521_095_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.01	25	25	25				36.71	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	095	0	1	04	01	H5521_095_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											776.66	25						916.98	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
H5521	099	0	1	04	01	H5521_099_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	099	0	1	04	01	H5521_099_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	099	0	1	04	01	H5521_099_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.19	24	24	24				119.54	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
H5521	099	0	1	04	01	H5521_099_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.48	25	25	25				40.33	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	099	0	1	04	01	H5521_099_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											817.46	25						639.31	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
H5521	101	0	1	04	01	H5521_101_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	101	0	1	04	01	H5521_101_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	101	0	1	04	01	H5521_101_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.67	24	24	24				101.50	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
H5521	101	0	1	04	01	H5521_101_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.99	25	25	25				34.44	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	101	0	1	04	01	H5521_101_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.88	25						777.68	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
H5521	110	0	1	04	01	H5521_110_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	110	0	1	04	01	H5521_110_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	110	0	1	04	01	H5521_110_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.47	22	22	22				107.04	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.88	25	25	25				43.97	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	110	0	1	04	01	H5521_110_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											891.56	27						660.07	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	116	0	1	04	01	H5521_116_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	116	0	1	04	01	H5521_116_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	116	0	1	04	01	H5521_116_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.44	24	24	24				103.66	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
H5521	116	0	1	04	01	H5521_116_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.90	25	25	25				34.78	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	116	0	1	04	01	H5521_116_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											753.92	25						935.21	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
H5521	117	0	1	04	01	H5521_117_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	117	0	1	04	01	H5521_117_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	117	0	1	04	01	H5521_117_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											102.46	24	24	24				119.18	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
H5521	117	0	1	04	01	H5521_117_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.47	25	25	25				43.84	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
H5521	117	0	1	04	01	H5521_117_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											989.24	25						984.01	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
H5521	119	0	1	04	01	H5521_119_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	119	0	1	04	01	H5521_119_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	119	0	1	04	01	H5521_119_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.34	24	24	24				120.15	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
H5521	119	0	1	04	01	H5521_119_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.45	25	25	25				43.19	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	119	0	1	04	01	H5521_119_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											871.39	25						720.64	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
H5521	120	0	1	04	01	H5521_120_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	120	0	1	04	01	H5521_120_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	120	0	1	04	01	H5521_120_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											113.08	24	24	24				121.24	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
H5521	120	0	1	04	01	H5521_120_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.80	25	25	25				45.97	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	120	0	1	04	01	H5521_120_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											812.25	25						808.11	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
H5521	121	0	1	04	01	H5521_121_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	121	0	1	04	01	H5521_121_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	121	0	1	04	01	H5521_121_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											112.29	24	24	24				119.50	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
H5521	121	0	1	04	01	H5521_121_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.39	25	25	25				46.11	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	121	0	1	04	01	H5521_121_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											733.08	25						964.32	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
H5521	122	0	1	04	01	H5521_122_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	122	0	1	04	01	H5521_122_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	122	0	1	04	01	H5521_122_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.34	24	24	24				104.53	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
H5521	122	0	1	04	01	H5521_122_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.61	25	25	25				39.48	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	122	0	1	04	01	H5521_122_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											858.49	25						801.59	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
H5521	123	0	1	04	01	H5521_123_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	123	0	1	04	01	H5521_123_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	123	0	1	04	01	H5521_123_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.19	22	22	22				105.11	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.18	25	25	25				42.37	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	123	0	1	04	01	H5521_123_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											766.70	27						812.67	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	124	0	1	04	01	H5521_124_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	124	0	1	04	01	H5521_124_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	124	0	1	04	01	H5521_124_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.22	22	22	22				107.99	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.69	25	25	25				35.11	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	124	0	1	04	01	H5521_124_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1053.70	27						1263.36	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	139	0	1	04	01	H5521_139_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	139	0	1	04	01	H5521_139_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	139	0	1	04	01	H5521_139_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.98	25	25	25				104.30	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	139	0	1	04	01	H5521_139_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.18	26	26	26				37.74	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											976.99	30						912.98	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	140	0	1	04	01	H5521_140_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	140	0	1	04	01	H5521_140_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	140	0	1	04	01	H5521_140_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.13	25	25	25				106.72	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	140	0	1	04	01	H5521_140_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.63	26	26	26				33.58	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1028.78	30						1020.57	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	141	0	1	04	01	H5521_141_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	141	0	1	04	01	H5521_141_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	141	0	1	04	01	H5521_141_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.29	25	25	25				105.08	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
H5521	141	0	1	04	01	H5521_141_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.42	26	26	26				35.07	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1041.13	30						827.47	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	150	0	1	04	01	H5521_150_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	150	0	1	04	01	H5521_150_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	150	0	1	04	01	H5521_150_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.48	25	25	25				90.22	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	150	0	1	04	01	H5521_150_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.44	35	35	35				28.12	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
H5521	150	0	1	04	01	H5521_150_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1087.26	33						1539.13	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	156	0	1	04	01	H5521_156_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	156	0	1	04	01	H5521_156_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	156	0	1	04	01	H5521_156_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.99	24	24	24				101.73	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
H5521	156	0	1	04	01	H5521_156_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.04	25	25	25				35.17	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	156	0	1	04	01	H5521_156_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											831.87	25						672.30	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
H5521	157	0	1	04	01	H5521_157_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	157	0	1	04	01	H5521_157_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	157	0	1	04	01	H5521_157_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.29	24	24	24				116.57	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
H5521	157	0	1	04	01	H5521_157_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.05	25	25	25				47.43	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	157	0	1	04	01	H5521_157_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											884.12	25						1003.46	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
H5521	159	0	1	04	01	H5521_159_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	159	0	1	04	01	H5521_159_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	159	0	1	04	01	H5521_159_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.46	22	22	22				104.89	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.98	25	25	25				39.09	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	159	0	1	04	01	H5521_159_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											816.29	27						802.60	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	160	0	1	04	01	H5521_160_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	160	0	1	04	01	H5521_160_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	160	0	1	04	01	H5521_160_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.54	25	25	25				92.59	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	160	0	1	04	01	H5521_160_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.01	35	35	35				33.88	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
H5521	160	0	1	04	01	H5521_160_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1106.22	33						791.32	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	169	0	1	04	01	H5521_169_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	169	0	1	04	01	H5521_169_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	169	0	1	04	01	H5521_169_0	2			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				103.17	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	169	0	1	04	01	H5521_169_0	2			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	26	26	26				34.04	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1092.20	30						995.06	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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	170	0	1	04	01	H5521_170_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	170	0	1	04	01	H5521_170_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.35	25	25	25				90.06	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	170	0	1	04	01	H5521_170_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.23	35	35	35				29.74	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
H5521	170	0	1	04	01	H5521_170_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1198.65	33						1132.08	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
H5521	171	0	1	04	01	H5521_171_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	171	0	1	04	01	H5521_171_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	171	0	1	04	01	H5521_171_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.87	24	24	24				105.61	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
H5521	171	0	1	04	01	H5521_171_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.26	25	25	25				33.65	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	171	0	1	04	01	H5521_171_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											703.44	25						598.55	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
H5521	178	0	1	04	01	H5521_178_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	178	0	1	04	01	H5521_178_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	178	0	1	04	01	H5521_178_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.74	24	24	24				103.22	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
H5521	178	0	1	04	01	H5521_178_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.81	25	25	25				30.90	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	178	0	1	04	01	H5521_178_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											776.66	25						707.62	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
H5521	194	0	1	04	01	H5521_194_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	194	0	1	04	01	H5521_194_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	194	0	1	04	01	H5521_194_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.86	24	24	24				106.30	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
H5521	194	0	1	04	01	H5521_194_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.79	25	25	25				35.29	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	194	0	1	04	01	H5521_194_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.38	25						893.52	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
H5521	195	0	1	04	01	H5521_195_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	195	0	1	04	01	H5521_195_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	195	0	1	04	01	H5521_195_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.39	24	24	24				117.63	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
H5521	195	0	1	04	01	H5521_195_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.07	25	25	25				30.72	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	195	0	1	04	01	H5521_195_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											800.54	25						1049.24	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
H5521	197	0	1	04	01	H5521_197_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	197	0	1	04	01	H5521_197_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	197	0	1	04	01	H5521_197_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.39	24	24	24				105.62	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
H5521	197	0	1	04	01	H5521_197_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.28	25	25	25				32.92	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	197	0	1	04	01	H5521_197_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											771.43	25						876.21	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
H5521	207	0	1	04	01	H5521_207_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	207	0	1	04	01	H5521_207_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	207	0	1	04	01	H5521_207_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.78	24	24	24				108.66	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
H5521	207	0	1	04	01	H5521_207_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.33	25	25	25				39.53	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	207	0	1	04	01	H5521_207_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											938.87	25						896.59	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
H5521	211	0	1	04	01	H5521_211_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	211	0	1	04	01	H5521_211_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	211	0	1	04	01	H5521_211_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.89	24	24	24				100.39	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
H5521	211	0	1	04	01	H5521_211_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.85	25	25	25				31.95	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	211	0	1	04	01	H5521_211_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											715.74	25						810.82	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
H5521	214	0	1	04	01	H5521_214_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	214	0	1	04	01	H5521_214_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	214	0	1	04	01	H5521_214_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.30	24	24	24				118.37	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
H5521	214	0	1	04	01	H5521_214_0	2			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	25	25	25				34.90	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	214	0	1	04	01	H5521_214_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											691.30	25						771.40	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
H5521	215	0	1	04	01	H5521_215_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	215	0	1	04	01	H5521_215_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	215	0	1	04	01	H5521_215_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.74	22	22	22				111.86	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.42	25	25	25				42.17	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	215	0	1	04	01	H5521_215_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.35	27						930.72	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	216	0	1	04	01	H5521_216_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	216	0	1	04	01	H5521_216_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	216	0	1	04	01	H5521_216_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.21	24	24	24				105.17	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
H5521	216	0	1	04	01	H5521_216_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.37	25	25	25				34.62	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	216	0	1	04	01	H5521_216_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											830.85	25						644.79	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
H5521	217	0	1	04	01	H5521_217_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	217	0	1	04	01	H5521_217_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	217	0	1	04	01	H5521_217_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.64	25	25	25				90.09	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	217	0	1	04	01	H5521_217_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.93	35	35	35				30.34	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
H5521	217	0	1	04	01	H5521_217_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1088.03	33						778.30	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	218	0	1	04	01	H5521_218_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	218	0	1	04	01	H5521_218_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	218	0	1	04	01	H5521_218_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											102.06	24	24	24				108.31	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
H5521	218	0	1	04	01	H5521_218_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.51	25	25	25				27.02	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	218	0	1	04	01	H5521_218_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											791.24	25						904.00	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
H5521	219	0	1	04	01	H5521_219_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	219	0	1	04	01	H5521_219_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	219	0	1	04	01	H5521_219_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.25	24	24	24				110.45	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
H5521	219	0	1	04	01	H5521_219_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.69	25	25	25				36.18	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	219	0	1	04	01	H5521_219_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											729.82	25						781.80	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
H5521	220	0	1	04	01	H5521_220_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	220	0	1	04	01	H5521_220_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	220	0	1	04	01	H5521_220_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.25	21	21	21				65.21	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	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	2			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	50	50	50				38.25	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
H5521	220	0	1	04	01	H5521_220_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1045.74	33						1143.17	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	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	222	0	1	04	01	H5521_222_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	222	0	1	04	01	H5521_222_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.56	24	24	24				104.74	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
H5521	222	0	1	04	01	H5521_222_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											34.57	25	25	25				30.94	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	222	0	1	04	01	H5521_222_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											665.91	25						942.87	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
H5521	223	0	1	04	01	H5521_223_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	223	0	1	04	01	H5521_223_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	223	0	1	04	01	H5521_223_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.98	24	24	24				112.21	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
H5521	223	0	1	04	01	H5521_223_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.82	25	25	25				34.76	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	223	0	1	04	01	H5521_223_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											783.21	25						611.10	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
H5521	224	0	1	04	01	H5521_224_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	224	0	1	04	01	H5521_224_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	224	0	1	04	01	H5521_224_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.55	24	24	24				102.77	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
H5521	224	0	1	04	01	H5521_224_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.18	25	25	25				33.87	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
H5521	224	0	1	04	01	H5521_224_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											853.64	25						846.32	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
H5521	227	0	1	04	01	H5521_227_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	227	0	1	04	01	H5521_227_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	227	0	1	04	01	H5521_227_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.68	24	24	24				102.28	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
H5521	227	0	1	04	01	H5521_227_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.81	25	25	25				32.24	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
H5521	227	0	1	04	01	H5521_227_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											718.77	25						638.73	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
H5521	230	0	1	04	01	H5521_230_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	230	0	1	04	01	H5521_230_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	230	0	1	04	01	H5521_230_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.10	21	21	21				66.31	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	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.90	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										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1098.04	33						859.74	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	231	0	1	04	01	H5521_231_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	231	0	1	04	01	H5521_231_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	231	0	1	04	01	H5521_231_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.06	24	24	24				112.62	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
H5521	231	0	1	04	01	H5521_231_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.72	25	25	25				35.27	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	231	0	1	04	01	H5521_231_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											919.03	25						639.21	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
H5521	232	0	1	04	01	H5521_232_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	232	0	1	04	01	H5521_232_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	232	0	1	04	01	H5521_232_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.39	24	24	24				100.80	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
H5521	232	0	1	04	01	H5521_232_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.21	25	25	25				35.68	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	232	0	1	04	01	H5521_232_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.64	25						824.24	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
H5521	233	0	1	04	01	H5521_233_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	233	0	1	04	01	H5521_233_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	233	0	1	04	01	H5521_233_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.77	21	21	21				70.65	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	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.32	50	50	50				35.10	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
H5521	233	0	1	04	01	H5521_233_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											974.53	33						1119.30	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	236	0	1	04	01	H5521_236_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	236	0	1	04	01	H5521_236_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	236	0	1	04	01	H5521_236_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.62	25	25	25				109.05	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	236	0	1	04	01	H5521_236_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.40	26	26	26				33.29	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1289.15	30						664.20	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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	243	0	1	04	01	H5521_243_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	243	0	1	04	01	H5521_243_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.19	25	25	25				108.74	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	243	0	1	04	01	H5521_243_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.11	26	26	26				33.76	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1163.04	30						1008.78	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
H5521	245	0	1	04	01	H5521_245_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	245	0	1	04	01	H5521_245_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	245	0	1	04	01	H5521_245_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.81	25	25	25				111.89	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	245	0	1	04	01	H5521_245_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.62	26	26	26				32.59	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1060.33	30						672.16	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	246	0	1	04	01	H5521_246_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	246	0	1	04	01	H5521_246_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	246	0	1	04	01	H5521_246_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.74	24	24	24				98.64	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
H5521	246	0	1	04	01	H5521_246_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.10	25	25	25				37.37	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	246	0	1	04	01	H5521_246_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											770.72	25						809.76	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
H5521	249	0	1	04	01	H5521_249_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	249	0	1	04	01	H5521_249_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	249	0	1	04	01	H5521_249_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.69	25	25	25				81.22	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	249	0	1	04	01	H5521_249_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.78	35	35	35				29.74	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
H5521	249	0	1	04	01	H5521_249_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1074.22	33						1020.06	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	250	0	1	04	01	H5521_250_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	250	0	1	04	01	H5521_250_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	250	0	1	04	01	H5521_250_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.50	24	24	24				104.30	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
H5521	250	0	1	04	01	H5521_250_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.63	25	25	25				38.51	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	250	0	1	04	01	H5521_250_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											749.10	25						765.14	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
H5521	251	0	1	04	01	H5521_251_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	251	0	1	04	01	H5521_251_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	251	0	1	04	01	H5521_251_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.96	25	25	25				100.62	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	251	0	1	04	01	H5521_251_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											46.50	26	26	26				37.91	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1056.12	30						1193.93	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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	254	0	1	04	01	H5521_254_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	254	0	1	04	01	H5521_254_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.02	25	25	25				105.25	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	254	0	1	04	01	H5521_254_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.60	26	26	26				32.00	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1053.76	30						667.82	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	259	0	1	04	01	H5521_259_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	259	0	1	04	01	H5521_259_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	259	0	1	04	01	H5521_259_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.09	25	25	25				94.15	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	259	0	1	04	01	H5521_259_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.44	26	26	26				33.87	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											951.81	30						949.23	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	260	0	1	04	01	H5521_260_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	260	0	1	04	01	H5521_260_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	260	0	1	04	01	H5521_260_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.99	24	24	24				99.49	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
H5521	260	0	1	04	01	H5521_260_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.42	25	25	25				34.37	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	260	0	1	04	01	H5521_260_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											824.33	25						750.13	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
H5521	261	0	1	04	01	H5521_261_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	261	0	1	04	01	H5521_261_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	261	0	1	04	01	H5521_261_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.14	24	24	24				107.73	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
H5521	261	0	1	04	01	H5521_261_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.25	25	25	25				37.46	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	261	0	1	04	01	H5521_261_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											759.74	25						884.35	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
H5521	263	0	1	04	01	H5521_263_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	263	0	1	04	01	H5521_263_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	263	0	1	04	01	H5521_263_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.54	24	24	24				111.80	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
H5521	263	0	1	04	01	H5521_263_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.58	25	25	25				38.80	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	263	0	1	04	01	H5521_263_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											753.31	25						714.21	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
H5521	269	0	1	04	01	H5521_269_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	269	0	1	04	01	H5521_269_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	269	0	1	04	01	H5521_269_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.36	24	24	24				107.32	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
H5521	269	0	1	04	01	H5521_269_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.48	25	25	25				35.78	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	269	0	1	04	01	H5521_269_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											861.94	25						918.14	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
H5521	270	0	1	04	01	H5521_270_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	270	0	1	04	01	H5521_270_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	270	0	1	04	01	H5521_270_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.85	24	24	24				109.55	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
H5521	270	0	1	04	01	H5521_270_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.27	25	25	25				38.72	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	270	0	1	04	01	H5521_270_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1049.31	25						957.05	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
H5521	271	0	1	04	01	H5521_271_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	271	0	1	04	01	H5521_271_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	271	0	1	04	01	H5521_271_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.59	24	24	24				106.61	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
H5521	271	0	1	04	01	H5521_271_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											40.91	25	25	25				33.76	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	271	0	1	04	01	H5521_271_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											714.06	25						895.42	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
H5521	272	0	1	04	01	H5521_272_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	272	0	1	04	01	H5521_272_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	272	0	1	04	01	H5521_272_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.80	24	24	24				110.69	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
H5521	272	0	1	04	01	H5521_272_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.79	25	25	25				42.78	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	272	0	1	04	01	H5521_272_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1069.44	25						806.76	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
H5521	273	0	1	04	01	H5521_273_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	273	0	1	04	01	H5521_273_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	273	0	1	04	01	H5521_273_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.60	24	24	24				109.41	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
H5521	273	0	1	04	01	H5521_273_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.70	25	25	25				45.44	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	273	0	1	04	01	H5521_273_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1000.67	25						914.66	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
H5521	275	0	1	04	01	H5521_275_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	275	0	1	04	01	H5521_275_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	275	0	1	04	01	H5521_275_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.82	24	24	24				124.45	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
H5521	275	0	1	04	01	H5521_275_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.13	25	25	25				43.60	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	275	0	1	04	01	H5521_275_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											874.59	25						744.48	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
H5521	277	0	1	04	01	H5521_277_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	277	0	1	04	01	H5521_277_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	277	0	1	04	01	H5521_277_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											98.65	24	24	24				120.72	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
H5521	277	0	1	04	01	H5521_277_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.94	25	25	25				42.45	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	277	0	1	04	01	H5521_277_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											947.44	25						1195.54	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
H5521	283	0	1	04	01	H5521_283_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	283	0	1	04	01	H5521_283_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	283	0	1	04	01	H5521_283_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.61	25	25	25				81.80	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	283	0	1	04	01	H5521_283_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.97	35	35	35				27.96	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
H5521	283	0	1	04	01	H5521_283_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											989.75	33						997.08	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
H5521	284	0	1	04	01	H5521_284_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	284	0	1	04	01	H5521_284_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	284	0	1	04	01	H5521_284_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.61	24	24	24				103.59	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
H5521	284	0	1	04	01	H5521_284_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.17	25	25	25				37.74	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	284	0	1	04	01	H5521_284_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											728.44	25						612.68	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
H5521	285	0	1	04	01	H5521_285_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	285	0	1	04	01	H5521_285_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	285	0	1	04	01	H5521_285_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.34	24	24	24				108.13	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
H5521	285	0	1	04	01	H5521_285_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.88	25	25	25				38.63	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	285	0	1	04	01	H5521_285_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											710.06	25						741.06	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
H5521	288	0	1	04	01	H5521_288_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	288	0	1	04	01	H5521_288_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	288	0	1	04	01	H5521_288_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.67	24	24	24				107.79	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
H5521	288	0	1	04	01	H5521_288_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.26	25	25	25				35.45	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	288	0	1	04	01	H5521_288_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											705.39	25						841.86	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
H5521	289	0	1	04	01	H5521_289_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	289	0	1	04	01	H5521_289_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	289	0	1	04	01	H5521_289_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.17	24	24	24				103.05	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
H5521	289	0	1	04	01	H5521_289_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.39	25	25	25				30.29	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	289	0	1	04	01	H5521_289_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.81	25						795.09	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
H5521	290	0	1	04	01	H5521_290_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	290	0	1	04	01	H5521_290_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	290	0	1	04	01	H5521_290_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.37	24	24	24				106.23	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
H5521	290	0	1	04	01	H5521_290_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.97	25	25	25				35.08	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
H5521	290	0	1	04	01	H5521_290_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											961.63	25						991.60	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
H5521	292	0	1	04	01	H5521_292_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	292	0	1	04	01	H5521_292_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	292	0	1	04	01	H5521_292_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.31	24	24	24				98.67	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
H5521	292	0	1	04	01	H5521_292_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.21	25	25	25				39.44	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	292	0	1	04	01	H5521_292_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											850.18	25						815.25	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
H5521	299	0	1	04	01	H5521_299_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	299	0	1	04	01	H5521_299_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	299	0	1	04	01	H5521_299_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.87	24	24	24				107.22	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
H5521	299	0	1	04	01	H5521_299_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.67	25	25	25				38.08	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
H5521	299	0	1	04	01	H5521_299_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											661.09	25						623.43	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
H5521	302	0	1	04	01	H5521_302_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	302	0	1	04	01	H5521_302_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	302	0	1	04	01	H5521_302_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.50	24	24	24				91.48	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
H5521	302	0	1	04	01	H5521_302_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											40.39	25	25	25				36.52	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	302	0	1	04	01	H5521_302_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											812.72	25						694.60	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
H5521	303	0	1	04	01	H5521_303_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	303	0	1	04	01	H5521_303_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	303	0	1	04	01	H5521_303_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.02	24	24	24				106.73	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
H5521	303	0	1	04	01	H5521_303_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.22	25	25	25				38.75	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	303	0	1	04	01	H5521_303_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											771.17	25						757.88	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
H5521	305	0	1	04	01	H5521_305_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	305	0	1	04	01	H5521_305_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	305	0	1	04	01	H5521_305_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.47	24	24	24				99.27	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
H5521	305	0	1	04	01	H5521_305_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.07	25	25	25				34.96	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	305	0	1	04	01	H5521_305_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											745.29	25						680.57	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
H5521	311	0	1	04	01	H5521_311_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	311	0	1	04	01	H5521_311_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	311	0	1	04	01	H5521_311_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.59	25	25	25				82.65	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	311	0	1	04	01	H5521_311_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.84	35	35	35				30.94	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
H5521	311	0	1	04	01	H5521_311_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											906.03	33						1159.44	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	312	0	1	04	01	H5521_312_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	312	0	1	04	01	H5521_312_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	312	0	1	04	01	H5521_312_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											117.64	24	24	24				123.71	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
H5521	312	0	1	04	01	H5521_312_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.77	25	25	25				50.81	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	312	0	1	04	01	H5521_312_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											791.32	25						788.88	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
H5521	314	0	1	04	01	H5521_314_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	314	0	1	04	01	H5521_314_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	314	0	1	04	01	H5521_314_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.79	25	25	25				93.01	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	314	0	1	04	01	H5521_314_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.72	35	35	35				27.27	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
H5521	314	0	1	04	01	H5521_314_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											936.67	33						940.32	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	319	0	1	04	01	H5521_319_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	319	0	1	04	01	H5521_319_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	319	0	1	04	01	H5521_319_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.51	25	25	25				90.54	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	319	0	1	04	01	H5521_319_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.22	35	35	35				25.64	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
H5521	319	0	1	04	01	H5521_319_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1448.57	33						971.42	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	326	0	1	04	01	H5521_326_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	326	0	1	04	01	H5521_326_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	326	0	1	04	01	H5521_326_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					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	326	0	1	04	01	H5521_326_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											811.98	25						798.37	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
H5521	328	0	1	04	01	H5521_328_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	328	0	1	04	01	H5521_328_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	328	0	1	04	01	H5521_328_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.72	24	24	24				108.39	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
H5521	328	0	1	04	01	H5521_328_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.55	25	25	25				33.71	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	328	0	1	04	01	H5521_328_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											829.36	25						1023.17	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
H5521	331	0	1	04	01	H5521_331_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	331	0	1	04	01	H5521_331_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	331	0	1	04	01	H5521_331_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.98	24	24	24				109.68	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
H5521	331	0	1	04	01	H5521_331_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.93	25	25	25				36.51	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	331	0	1	04	01	H5521_331_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.58	25						890.82	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
H5521	332	0	1	04	01	H5521_332_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	332	0	1	04	01	H5521_332_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	332	0	1	04	01	H5521_332_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.53	24	24	24				105.73	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
H5521	332	0	1	04	01	H5521_332_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.95	25	25	25				36.78	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	332	0	1	04	01	H5521_332_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.82	25						741.69	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
H5521	340	0	1	04	01	H5521_340_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	340	0	1	04	01	H5521_340_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	340	0	1	04	01	H5521_340_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.01	24	24	24				105.98	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
H5521	340	0	1	04	01	H5521_340_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.93	25	25	25				39.74	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	340	0	1	04	01	H5521_340_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											734.79	25						722.92	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
H5521	348	0	1	04	01	H5521_348_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	348	0	1	04	01	H5521_348_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	348	0	1	04	01	H5521_348_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.83	24	24	24				107.65	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
H5521	348	0	1	04	01	H5521_348_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.78	25	25	25				37.56	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
H5521	348	0	1	04	01	H5521_348_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											815.92	25						842.55	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
H5521	352	0	1	04	01	H5521_352_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	352	0	1	04	01	H5521_352_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	352	0	1	04	01	H5521_352_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.61	22	22	22				110.56	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.89	25	25	25				43.25	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	352	0	1	04	01	H5521_352_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1034.44	27						883.40	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	363	0	1	04	01	H5521_363_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	363	0	1	04	01	H5521_363_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	363	0	1	04	01	H5521_363_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.60	24	24	24				107.22	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
H5521	363	0	1	04	01	H5521_363_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.37	25	25	25				35.67	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
H5521	363	0	1	04	01	H5521_363_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											921.52	25						835.03	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
H5521	364	0	1	04	01	H5521_364_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	364	0	1	04	01	H5521_364_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	364	0	1	04	01	H5521_364_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.45	24	24	24				101.34	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
H5521	364	0	1	04	01	H5521_364_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											48.28	25	25	25				43.29	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	364	0	1	04	01	H5521_364_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											792.55	25						857.53	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
H5521	365	0	1	04	01	H5521_365_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	365	0	1	04	01	H5521_365_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	365	0	1	04	01	H5521_365_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.24	24	24	24				100.11	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
H5521	365	0	1	04	01	H5521_365_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.00	25	25	25				33.85	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	365	0	1	04	01	H5521_365_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											697.98	25						719.79	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
H5521	370	0	1	04	01	H5521_370_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	370	0	1	04	01	H5521_370_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	370	0	1	04	01	H5521_370_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.82	24	24	24				104.93	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
H5521	370	0	1	04	01	H5521_370_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.23	25	25	25				37.87	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
H5521	370	0	1	04	01	H5521_370_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											876.62	25						702.96	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
H5521	371	0	1	04	01	H5521_371_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	371	0	1	04	01	H5521_371_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	371	0	1	04	01	H5521_371_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.92	24	24	24				102.52	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
H5521	371	0	1	04	01	H5521_371_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.32	25	25	25				35.01	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	371	0	1	04	01	H5521_371_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											700.06	25						704.16	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
H5521	374	0	1	04	01	H5521_374_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	374	0	1	04	01	H5521_374_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	374	0	1	04	01	H5521_374_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.52	25	25	25				114.43	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	374	0	1	04	01	H5521_374_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.72	26	26	26				36.42	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											832.07	30						1450.76	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
H5521	375	0	1	04	01	H5521_375_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	375	0	1	04	01	H5521_375_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	375	0	1	04	01	H5521_375_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.29	25	25	25				86.84	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
H5521	375	0	1	04	01	H5521_375_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.76	35	35	35				31.82	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
H5521	375	0	1	04	01	H5521_375_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1270.79	33						1006.37	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
H5521	376	0	1	04	01	H5521_376_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	376	0	1	04	01	H5521_376_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	376	0	1	04	01	H5521_376_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.16	24	24	24				101.98	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
H5521	376	0	1	04	01	H5521_376_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											42.86	25	25	25				39.69	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	376	0	1	04	01	H5521_376_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											743.38	25						735.35	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
H5521	377	0	1	04	01	H5521_377_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	377	0	1	04	01	H5521_377_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	377	0	1	04	01	H5521_377_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.15	24	24	24				99.42	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
H5521	377	0	1	04	01	H5521_377_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.59	25	25	25				31.01	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	377	0	1	04	01	H5521_377_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											729.03	25						750.85	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
H5521	380	0	1	04	01	H5521_380_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	380	0	1	04	01	H5521_380_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	380	0	1	04	01	H5521_380_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.35	22	22	22				106.06	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			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	25	25	25				30.21	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	380	0	1	04	01	H5521_380_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											812.35	27						1034.38	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	381	0	1	04	01	H5521_381_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	381	0	1	04	01	H5521_381_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	381	0	1	04	01	H5521_381_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.98	22	22	22				103.31	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.20	25	25	25				44.18	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	381	0	1	04	01	H5521_381_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											890.24	27						886.32	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	386	0	1	04	01	H5521_386_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	386	0	1	04	01	H5521_386_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	386	0	1	04	01	H5521_386_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.33	24	24	24				103.49	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
H5521	386	0	1	04	01	H5521_386_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.87	25	25	25				32.17	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											804.96	25						776.88	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
H5521	388	0	1	04	01	H5521_388_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	388	0	1	04	01	H5521_388_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	388	0	1	04	01	H5521_388_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.67	25	25	25				81.20	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
H5521	388	0	1	04	01	H5521_388_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.98	35	35	35				29.48	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
H5521	388	0	1	04	01	H5521_388_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1010.23	33						1028.41	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
H5521	392	0	1	04	01	H5521_392_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	392	0	1	04	01	H5521_392_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	392	0	1	04	01	H5521_392_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.46	22	22	22				109.49	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.19	25	25	25				40.62	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	392	0	1	04	01	H5521_392_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											883.95	27						836.88	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	395	0	1	04	01	H5521_395_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	395	0	1	04	01	H5521_395_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	395	0	1	04	01	H5521_395_0	2			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				100.60	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	395	0	1	04	01	H5521_395_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.85	26	26	26				34.38	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											900.69	30						904.13	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	399	0	1	04	01	H5521_399_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	399	0	1	04	01	H5521_399_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	399	0	1	04	01	H5521_399_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.80	24	24	24				98.70	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
H5521	399	0	1	04	01	H5521_399_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.52	25	25	25				39.80	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	399	0	1	04	01	H5521_399_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											706.99	25						697.50	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
H5521	400	0	1	04	01	H5521_400_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	400	0	1	04	01	H5521_400_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	400	0	1	04	01	H5521_400_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.34	24	24	24				104.48	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
H5521	400	0	1	04	01	H5521_400_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.47	25	25	25				41.67	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
H5521	400	0	1	04	01	H5521_400_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											763.02	25						753.96	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
H5521	403	0	1	04	01	H5521_403_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	403	0	1	04	01	H5521_403_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	403	0	1	04	01	H5521_403_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.27	24	24	24				104.53	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
H5521	403	0	1	04	01	H5521_403_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.38	25	25	25				33.58	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
H5521	403	0	1	04	01	H5521_403_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											815.41	25						777.79	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
H5521	404	0	1	04	01	H5521_404_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	404	0	1	04	01	H5521_404_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	404	0	1	04	01	H5521_404_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.57	24	24	24				106.50	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
H5521	404	0	1	04	01	H5521_404_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.57	25	25	25				34.53	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	404	0	1	04	01	H5521_404_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											788.66	25						754.12	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
H5521	405	0	1	04	01	H5521_405_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	405	0	1	04	01	H5521_405_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	405	0	1	04	01	H5521_405_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.71	24	24	24				104.68	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
H5521	405	0	1	04	01	H5521_405_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.93	25	25	25				34.32	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
H5521	405	0	1	04	01	H5521_405_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											798.85	25						775.13	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
H5521	406	0	1	04	01	H5521_406_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	406	0	1	04	01	H5521_406_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	406	0	1	04	01	H5521_406_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.19	24	24	24				104.88	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
H5521	406	0	1	04	01	H5521_406_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.63	25	25	25				33.73	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	406	0	1	04	01	H5521_406_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											806.85	25						780.09	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
H5521	407	0	1	04	01	H5521_407_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	407	0	1	04	01	H5521_407_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	407	0	1	04	01	H5521_407_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.57	24	24	24				106.49	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
H5521	407	0	1	04	01	H5521_407_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.57	25	25	25				34.53	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	407	0	1	04	01	H5521_407_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											788.57	25						753.71	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
H5521	408	0	1	04	01	H5521_408_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	408	0	1	04	01	H5521_408_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	408	0	1	04	01	H5521_408_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.71	24	24	24				104.68	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
H5521	408	0	1	04	01	H5521_408_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.93	25	25	25				34.33	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	408	0	1	04	01	H5521_408_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											798.85	25						776.20	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
H5521	409	0	1	04	01	H5521_409_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	409	0	1	04	01	H5521_409_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	409	0	1	04	01	H5521_409_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.71	24	24	24				104.68	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
H5521	409	0	1	04	01	H5521_409_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.93	25	25	25				34.32	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
H5521	409	0	1	04	01	H5521_409_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											798.85	25						775.53	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
H5521	414	0	1	04	01	H5521_414_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	414	0	1	04	01	H5521_414_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	414	0	1	04	01	H5521_414_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.63	24	24	24				108.34	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
H5521	414	0	1	04	01	H5521_414_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.83	25	25	25				42.13	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	414	0	1	04	01	H5521_414_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.39	25						782.93	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
H5521	419	0	1	04	01	H5521_419_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	419	0	1	04	01	H5521_419_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	419	0	1	04	01	H5521_419_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.95	24	24	24				101.73	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
H5521	419	0	1	04	01	H5521_419_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	25	25	25				34.82	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
H5521	419	0	1	04	01	H5521_419_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.73	25						675.26	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
H5521	421	0	1	04	01	H5521_421_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	421	0	1	04	01	H5521_421_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	421	0	1	04	01	H5521_421_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.95	24	24	24				101.73	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
H5521	421	0	1	04	01	H5521_421_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	25	25	25				34.81	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	421	0	1	04	01	H5521_421_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.73	25						674.29	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
H5521	422	0	1	04	01	H5521_422_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	422	0	1	04	01	H5521_422_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	422	0	1	04	01	H5521_422_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.95	24	24	24				101.73	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
H5521	422	0	1	04	01	H5521_422_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	25	25	25				34.81	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	422	0	1	04	01	H5521_422_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.73	25						674.82	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
H5521	424	0	1	04	01	H5521_424_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	424	0	1	04	01	H5521_424_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	424	0	1	04	01	H5521_424_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.92	24	24	24				108.00	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
H5521	424	0	1	04	01	H5521_424_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.91	25	25	25				42.66	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
H5521	424	0	1	04	01	H5521_424_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.65	25						761.84	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
H5521	425	0	1	04	01	H5521_425_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	425	0	1	04	01	H5521_425_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	425	0	1	04	01	H5521_425_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.19	24	24	24				108.39	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
H5521	425	0	1	04	01	H5521_425_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.00	25	25	25				39.41	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	425	0	1	04	01	H5521_425_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											781.29	25						872.39	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
H5521	431	0	1	04	01	H5521_431_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	431	0	1	04	01	H5521_431_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	431	0	1	04	01	H5521_431_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.14	24	24	24				107.77	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
H5521	431	0	1	04	01	H5521_431_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.23	25	25	25				33.33	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	431	0	1	04	01	H5521_431_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											832.40	25						778.61	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
H5521	432	0	1	04	01	H5521_432_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	432	0	1	04	01	H5521_432_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	432	0	1	04	01	H5521_432_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.99	24	24	24				98.35	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
H5521	432	0	1	04	01	H5521_432_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.29	25	25	25				30.94	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	432	0	1	04	01	H5521_432_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											711.00	25						734.39	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
H5521	433	0	1	04	01	H5521_433_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	433	0	1	04	01	H5521_433_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	433	0	1	04	01	H5521_433_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.03	24	24	24				98.66	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
H5521	433	0	1	04	01	H5521_433_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.96	25	25	25				30.97	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	433	0	1	04	01	H5521_433_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											722.56	25						730.84	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
H5521	434	0	1	04	01	H5521_434_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	434	0	1	04	01	H5521_434_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	434	0	1	04	01	H5521_434_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.23	24	24	24				98.50	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
H5521	434	0	1	04	01	H5521_434_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.25	25	25	25				30.89	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	434	0	1	04	01	H5521_434_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											714.97	25						737.15	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
H5521	435	0	1	04	01	H5521_435_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	435	0	1	04	01	H5521_435_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	435	0	1	04	01	H5521_435_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.22	24	24	24				98.59	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
H5521	435	0	1	04	01	H5521_435_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.15	25	25	25				30.90	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	435	0	1	04	01	H5521_435_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											718.33	25						735.10	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
H5521	437	0	1	04	01	H5521_437_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	437	0	1	04	01	H5521_437_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	437	0	1	04	01	H5521_437_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.45	24	24	24				98.49	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
H5521	437	0	1	04	01	H5521_437_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.38	25	25	25				30.83	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	437	0	1	04	01	H5521_437_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											713.27	25						741.58	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
H5521	438	0	1	04	01	H5521_438_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	438	0	1	04	01	H5521_438_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	438	0	1	04	01	H5521_438_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.45	24	24	24				98.55	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
H5521	438	0	1	04	01	H5521_438_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.32	25	25	25				30.84	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
H5521	438	0	1	04	01	H5521_438_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											715.40	25						741.50	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
H5521	439	0	1	04	01	H5521_439_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	439	0	1	04	01	H5521_439_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	439	0	1	04	01	H5521_439_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.97	24	24	24				98.36	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
H5521	439	0	1	04	01	H5521_439_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.26	25	25	25				30.95	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	439	0	1	04	01	H5521_439_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											711.66	25						734.24	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
H5521	442	0	1	04	01	H5521_442_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	442	0	1	04	01	H5521_442_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	442	0	1	04	01	H5521_442_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.14	24	24	24				105.23	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
H5521	442	0	1	04	01	H5521_442_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.05	25	25	25				32.68	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	442	0	1	04	01	H5521_442_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											823.75	25						791.98	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
H5521	443	0	1	04	01	H5521_443_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	443	0	1	04	01	H5521_443_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	443	0	1	04	01	H5521_443_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.99	24	24	24				106.19	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
H5521	443	0	1	04	01	H5521_443_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.93	25	25	25				42.76	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	443	0	1	04	01	H5521_443_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											761.33	25						750.58	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
H5521	446	0	1	04	01	H5521_446_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	446	0	1	04	01	H5521_446_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	446	0	1	04	01	H5521_446_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.00	22	22	22				98.30	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.28	25	25	25				34.23	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	446	0	1	04	01	H5521_446_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											888.71	27						841.25	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	449	0	1	04	01	H5521_449_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	449	0	1	04	01	H5521_449_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	449	0	1	04	01	H5521_449_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.92	24	24	24				100.43	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
H5521	449	0	1	04	01	H5521_449_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.73	25	25	25				39.62	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	449	0	1	04	01	H5521_449_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											722.06	25						710.10	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
H5521	450	0	1	04	01	H5521_450_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	450	0	1	04	01	H5521_450_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	450	0	1	04	01	H5521_450_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.70	25	25	25				101.76	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	450	0	1	04	01	H5521_450_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.34	26	26	26				38.23	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											883.19	30						867.92	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
H5521	451	0	1	04	01	H5521_451_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	451	0	1	04	01	H5521_451_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	451	0	1	04	01	H5521_451_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.67	25	25	25				101.72	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	451	0	1	04	01	H5521_451_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.34	26	26	26				38.28	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											882.75	30						868.71	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	456	0	1	04	01	H5521_456_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	456	0	1	04	01	H5521_456_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	456	0	1	04	01	H5521_456_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.18	22	22	22				120.15	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.22	25	25	25				41.08	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
H5521	456	0	1	04	01	H5521_456_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1068.30	27						1031.15	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	457	0	1	04	01	H5521_457_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	457	0	1	04	01	H5521_457_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	457	0	1	04	01	H5521_457_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.25	24	24	24				123.71	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
H5521	457	0	1	04	01	H5521_457_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.59	25	25	25				40.92	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	457	0	1	04	01	H5521_457_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											907.28	25						880.82	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
H5521	459	0	1	04	01	H5521_459_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	459	0	1	04	01	H5521_459_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	459	0	1	04	01	H5521_459_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											98.63	24	24	24				126.22	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
H5521	459	0	1	04	01	H5521_459_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.36	25	25	25				39.50	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	459	0	1	04	01	H5521_459_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											952.87	25						917.16	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
H5521	467	0	1	04	01	H5521_467_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	467	0	1	04	01	H5521_467_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	467	0	1	04	01	H5521_467_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					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	467	0	1	04	01	H5521_467_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											790.09	25						763.58	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
H5521	470	0	1	04	01	H5521_470_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	470	0	1	04	01	H5521_470_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	470	0	1	04	01	H5521_470_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.77	24	24	24				95.76	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
H5521	470	0	1	04	01	H5521_470_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.29	25	25	25				38.59	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	470	0	1	04	01	H5521_470_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											692.95	25						683.78	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
H5521	471	0	1	04	01	H5521_471_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	471	0	1	04	01	H5521_471_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	471	0	1	04	01	H5521_471_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											51.67	21	21	21				62.82	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	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.62	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										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											915.43	33						933.84	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
H5521	474	0	1	04	01	H5521_474_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	474	0	1	04	01	H5521_474_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	474	0	1	04	01	H5521_474_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.54	25	25	25				83.66	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
H5521	474	0	1	04	01	H5521_474_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.46	35	35	35				40.81	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
H5521	474	0	1	04	01	H5521_474_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											934.15	33						939.84	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
H5521	475	0	1	04	01	H5521_475_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	475	0	1	04	01	H5521_475_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	475	0	1	04	01	H5521_475_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.38	24	24	24				102.84	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
H5521	475	0	1	04	01	H5521_475_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.09	25	25	25				34.34	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	475	0	1	04	01	H5521_475_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											771.12	25						747.10	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
H5521	476	0	1	04	01	H5521_476_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	476	0	1	04	01	H5521_476_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	476	0	1	04	01	H5521_476_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.13	24	24	24				100.96	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
H5521	476	0	1	04	01	H5521_476_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.36	25	25	25				33.60	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	476	0	1	04	01	H5521_476_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											760.26	25						737.52	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
H5521	477	0	1	04	01	H5521_477_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	477	0	1	04	01	H5521_477_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	477	0	1	04	01	H5521_477_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.69	24	24	24				95.87	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
H5521	477	0	1	04	01	H5521_477_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.43	25	25	25				31.68	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	477	0	1	04	01	H5521_477_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											731.05	25						705.96	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
H5521	478	0	1	04	01	H5521_478_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	478	0	1	04	01	H5521_478_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	478	0	1	04	01	H5521_478_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.02	22	22	22				38.66	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	478	0	1	04	01	H5521_478_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.76	25	25	25				44.30	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	478	0	1	04	01	H5521_478_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											327.58	25						289.78	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
H5521	482	0	1	04	01	H5521_482_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	482	0	1	04	01	H5521_482_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	482	0	1	04	01	H5521_482_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.57	24	24	24				112.17	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
H5521	482	0	1	04	01	H5521_482_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.31	25	25	25				45.03	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	482	0	1	04	01	H5521_482_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.19	25						795.23	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
H5521	484	0	1	04	01	H5521_484_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	484	0	1	04	01	H5521_484_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	484	0	1	04	01	H5521_484_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.16	25	25	25				100.58	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
H5521	484	0	1	04	01	H5521_484_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.14	26	26	26				34.67	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	484	0	1	04	01	H5521_484_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											953.02	30						901.14	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
H5521	490	0	1	04	01	H5521_490_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	490	0	1	04	01	H5521_490_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	490	0	1	04	01	H5521_490_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.45	25	25	25				101.51	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	490	0	1	04	01	H5521_490_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.05	26	26	26				41.18	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	490	0	1	04	01	H5521_490_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											894.85	30						892.20	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	492	0	1	04	01	H5521_492_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	492	0	1	04	01	H5521_492_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	492	0	1	04	01	H5521_492_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.64	22	22	22				39.75	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	492	0	1	04	01	H5521_492_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.87	25	25	25				46.11	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	492	0	1	04	01	H5521_492_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											345.94	25						308.55	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
H5521	495	0	1	04	01	H5521_495_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	495	0	1	04	01	H5521_495_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	495	0	1	04	01	H5521_495_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.58	25	25	25				105.74	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	495	0	1	04	01	H5521_495_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.74	26	26	26				35.10	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	495	0	1	04	01	H5521_495_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1033.52	30						958.53	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
H5521	496	0	1	04	01	H5521_496_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	496	0	1	04	01	H5521_496_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	496	0	1	04	01	H5521_496_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											30.34	22	22	22				37.77	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	496	0	1	04	01	H5521_496_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											47.19	25	25	25				49.08	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
H5521	496	0	1	04	01	H5521_496_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											359.75	25						336.05	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
H5521	497	0	1	04	01	H5521_497_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	497	0	1	04	01	H5521_497_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	497	0	1	04	01	H5521_497_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											30.34	22	22	22				37.77	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	497	0	1	04	01	H5521_497_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.19	25	25	25				49.07	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	497	0	1	04	01	H5521_497_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											359.75	25						336.06	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
H5521	498	0	1	04	01	H5521_498_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	498	0	1	04	01	H5521_498_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	498	0	1	04	01	H5521_498_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.29	22	22	22				40.44	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	498	0	1	04	01	H5521_498_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.07	25	25	25				43.93	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	498	0	1	04	01	H5521_498_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											347.06	25						306.46	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
H5521	499	0	1	04	01	H5521_499_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	499	0	1	04	01	H5521_499_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	499	0	1	04	01	H5521_499_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.52	22	22	22				39.67	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	499	0	1	04	01	H5521_499_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.69	25	25	25				42.76	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	499	0	1	04	01	H5521_499_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											344.02	25						303.36	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
H5521	500	0	1	04	01	H5521_500_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	500	0	1	04	01	H5521_500_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	500	0	1	04	01	H5521_500_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.45	25	25	25				80.50	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	500	0	1	04	01	H5521_500_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.94	35	35	35				28.45	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
H5521	500	0	1	04	01	H5521_500_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1090.79	33						1048.99	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	501	0	1	04	01	H5521_501_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	501	0	1	04	01	H5521_501_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	501	0	1	04	01	H5521_501_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.07	25	25	25				100.51	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	501	0	1	04	01	H5521_501_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.22	26	26	26				40.75	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	501	0	1	04	01	H5521_501_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											872.59	30						865.13	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	502	0	1	04	01	H5521_502_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	502	0	1	04	01	H5521_502_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	502	0	1	04	01	H5521_502_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.99	25	25	25				77.33	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	502	0	1	04	01	H5521_502_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.95	35	35	35				27.72	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
H5521	502	0	1	04	01	H5521_502_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1037.94	33						1008.43	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
H5521	509	0	1	04	01	H5521_509_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	509	0	1	04	01	H5521_509_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	509	0	1	04	01	H5521_509_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.27	22	22	22				94.97	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	509	0	1	04	01	H5521_509_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.42	25	25	25				37.33	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	509	0	1	04	01	H5521_509_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											834.12	27						794.14	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	510	0	1	04	01	H5521_510_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	510	0	1	04	01	H5521_510_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	510	0	1	04	01	H5521_510_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.21	22	22	22				119.36	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	510	0	1	04	01	H5521_510_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.77	25	25	25				42.43	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	510	0	1	04	01	H5521_510_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1112.84	27						1023.13	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	511	0	1	04	01	H5521_511_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	511	0	1	04	01	H5521_511_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	511	0	1	04	01	H5521_511_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.53	22	22	22				49.46	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	511	0	1	04	01	H5521_511_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.84	25	25	25				52.68	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	511	0	1	04	01	H5521_511_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											426.59	25						379.32	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
H5521	512	0	1	04	01	H5521_512_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	512	0	1	04	01	H5521_512_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	512	0	1	04	01	H5521_512_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.07	22	22	22				119.26	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	512	0	1	04	01	H5521_512_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.77	25	25	25				42.46	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	512	0	1	04	01	H5521_512_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1109.40	27						1021.15	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	513	0	1	04	01	H5521_513_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	513	0	1	04	01	H5521_513_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	513	0	1	04	01	H5521_513_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.70	22	22	22				118.98	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	513	0	1	04	01	H5521_513_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.76	25	25	25				42.57	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	513	0	1	04	01	H5521_513_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1100.22	27						1020.45	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	514	0	1	04	01	H5521_514_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	514	0	1	04	01	H5521_514_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	514	0	1	04	01	H5521_514_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.53	22	22	22				49.46	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	514	0	1	04	01	H5521_514_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.84	25	25	25				52.70	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	514	0	1	04	01	H5521_514_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											426.59	25						379.25	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
H5521	515	0	1	04	01	H5521_515_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	515	0	1	04	01	H5521_515_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	515	0	1	04	01	H5521_515_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											100.39	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
H5521	515	0	1	04	01	H5521_515_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.47	25	25	25				42.62	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	515	0	1	04	01	H5521_515_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1022.18	25						945.12	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
H5521	520	0	1	04	01	H5521_520_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	520	0	1	04	01	H5521_520_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	520	0	1	04	01	H5521_520_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.34	22	22	22				47.35	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	520	0	1	04	01	H5521_520_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.27	25	25	25				50.63	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	520	0	1	04	01	H5521_520_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											410.06	25						364.43	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
H5521	521	0	1	04	01	H5521_521_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	521	0	1	04	01	H5521_521_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	521	0	1	04	01	H5521_521_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.19	22	22	22				47.25	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	521	0	1	04	01	H5521_521_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.29	25	25	25				50.73	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	521	0	1	04	01	H5521_521_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											409.78	25						364.64	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
H5521	522	0	1	04	01	H5521_522_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	522	0	1	04	01	H5521_522_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	522	0	1	04	01	H5521_522_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.19	22	22	22				47.25	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	522	0	1	04	01	H5521_522_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.29	25	25	25				50.75	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	522	0	1	04	01	H5521_522_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											409.78	25						364.57	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
H5521	536	0	1	04	01	H5521_536_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	536	0	1	04	01	H5521_536_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	536	0	1	04	01	H5521_536_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.44	22	22	22				47.41	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	536	0	1	04	01	H5521_536_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.26	25	25	25				50.57	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	536	0	1	04	01	H5521_536_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											410.24	25						364.29	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
H5521	537	0	1	04	01	H5521_537_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	537	0	1	04	01	H5521_537_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	537	0	1	04	01	H5521_537_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.44	22	22	22				47.41	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	537	0	1	04	01	H5521_537_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.26	25	25	25				50.58	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
H5521	537	0	1	04	01	H5521_537_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											410.24	25						364.26	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
H5521	543	0	1	04	01	H5521_543_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	543	0	1	04	01	H5521_543_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	543	0	1	04	01	H5521_543_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.08	24	24	24				108.55	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
H5521	543	0	1	04	01	H5521_543_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.15	25	25	25				34.98	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
H5521	543	0	1	04	01	H5521_543_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											880.25	25						805.97	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
H5521	550	0	1	04	01	H5521_550_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	550	0	1	04	01	H5521_550_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	550	0	1	04	01	H5521_550_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											79.01	24	24	24				100.29	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
H5521	550	0	1	04	01	H5521_550_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.96	25	25	25				34.34	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	550	0	1	04	01	H5521_550_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											779.19	25						734.12	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
H5521	551	0	1	04	01	H5521_551_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	551	0	1	04	01	H5521_551_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	551	0	1	04	01	H5521_551_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.80	24	24	24				100.24	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
H5521	551	0	1	04	01	H5521_551_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.48	25	25	25				35.11	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	551	0	1	04	01	H5521_551_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											767.52	25						730.78	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
H5521	553	0	1	04	01	H5521_553_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	553	0	1	04	01	H5521_553_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	553	0	1	04	01	H5521_553_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											30.27	22	22	22				36.22	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	553	0	1	04	01	H5521_553_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.51	25	25	25				40.18	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	553	0	1	04	01	H5521_553_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											318.20	25						284.79	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
H5521	554	0	1	04	01	H5521_554_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	554	0	1	04	01	H5521_554_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	554	0	1	04	01	H5521_554_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.39	24	24	24				108.54	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
H5521	554	0	1	04	01	H5521_554_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.41	25	25	25				36.06	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	554	0	1	04	01	H5521_554_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											857.92	25						795.42	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
H5521	557	0	1	04	01	H5521_557_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	557	0	1	04	01	H5521_557_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	557	0	1	04	01	H5521_557_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.40	25	25	25				78.88	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	557	0	1	04	01	H5521_557_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.20	35	35	35				27.53	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
H5521	557	0	1	04	01	H5521_557_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1074.30	33						1012.60	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	558	0	1	04	01	H5521_558_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	558	0	1	04	01	H5521_558_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	558	0	1	04	01	H5521_558_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.22	24	24	24				105.30	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
H5521	558	0	1	04	01	H5521_558_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.69	25	25	25				34.60	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	558	0	1	04	01	H5521_558_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											822.54	25						763.17	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
H5521	565	0	1	04	01	H5521_565_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	565	0	1	04	01	H5521_565_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	565	0	1	04	01	H5521_565_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.29	22	22	22				41.72	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	565	0	1	04	01	H5521_565_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.84	25	25	25				43.91	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	565	0	1	04	01	H5521_565_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											358.86	25						315.14	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
H5521	569	0	1	04	01	H5521_569_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	569	0	1	04	01	H5521_569_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	569	0	1	04	01	H5521_569_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.45	22	22	22				38.50	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	569	0	1	04	01	H5521_569_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.73	25	25	25				39.95	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	569	0	1	04	01	H5521_569_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											322.60	25						278.10	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
H5521	574	0	1	04	01	H5521_574_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	574	0	1	04	01	H5521_574_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	574	0	1	04	01	H5521_574_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.40	22	22	22				38.47	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	574	0	1	04	01	H5521_574_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.73	25	25	25				39.93	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	574	0	1	04	01	H5521_574_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											322.42	25						278.19	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
H5521	578	0	1	04	01	H5521_578_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	578	0	1	04	01	H5521_578_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	578	0	1	04	01	H5521_578_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.02	22	22	22				38.66	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	578	0	1	04	01	H5521_578_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.76	25	25	25				44.29	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	578	0	1	04	01	H5521_578_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											327.58	25						289.80	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
H5521	579	0	1	04	01	H5521_579_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	579	0	1	04	01	H5521_579_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	579	0	1	04	01	H5521_579_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.02	22	22	22				38.66	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	579	0	1	04	01	H5521_579_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.76	25	25	25				44.29	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	579	0	1	04	01	H5521_579_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											327.58	25						289.80	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
H5521	580	0	1	04	01	H5521_580_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	580	0	1	04	01	H5521_580_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	580	0	1	04	01	H5521_580_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.02	22	22	22				38.66	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	580	0	1	04	01	H5521_580_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.76	25	25	25				44.28	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	580	0	1	04	01	H5521_580_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											327.58	25						289.82	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
H5521	581	0	1	04	01	H5521_581_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	581	0	1	04	01	H5521_581_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	581	0	1	04	01	H5521_581_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.02	22	22	22				38.66	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	581	0	1	04	01	H5521_581_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.76	25	25	25				44.29	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	581	0	1	04	01	H5521_581_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											327.58	25						289.79	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
H5521	584	0	1	04	01	H5521_584_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	584	0	1	04	01	H5521_584_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	584	0	1	04	01	H5521_584_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.43	22	22	22				39.43	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	584	0	1	04	01	H5521_584_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.01	25	25	25				43.11	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	584	0	1	04	01	H5521_584_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											347.85	25						311.51	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
H5521	586	0	1	04	01	H5521_586_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	586	0	1	04	01	H5521_586_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	586	0	1	04	01	H5521_586_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.45	22	22	22				38.50	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	586	0	1	04	01	H5521_586_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.73	25	25	25				39.95	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	586	0	1	04	01	H5521_586_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											322.60	25						278.10	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
H5521	590	0	1	04	01	H5521_590_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	590	0	1	04	01	H5521_590_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	590	0	1	04	01	H5521_590_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.71	22	22	22				39.55	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	590	0	1	04	01	H5521_590_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.73	25	25	25				42.62	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	590	0	1	04	01	H5521_590_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											346.65	25						308.83	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
H5521	592	0	1	04	01	H5521_592_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	592	0	1	04	01	H5521_592_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	592	0	1	04	01	H5521_592_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.40	22	22	22				38.47	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	592	0	1	04	01	H5521_592_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.73	25	25	25				39.95	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	592	0	1	04	01	H5521_592_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											322.42	25						278.13	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
H5521	593	0	1	04	01	H5521_593_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	593	0	1	04	01	H5521_593_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	593	0	1	04	01	H5521_593_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.43	25	25	25				78.08	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
H5521	593	0	1	04	01	H5521_593_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.13	35	35	35				27.09	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
H5521	593	0	1	04	01	H5521_593_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1086.45	33						1041.81	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	598	0	1	04	01	H5521_598_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	598	0	1	04	01	H5521_598_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	598	0	1	04	01	H5521_598_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.93	22	22	22				42.46	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	598	0	1	04	01	H5521_598_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.32	25	25	25				46.19	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	598	0	1	04	01	H5521_598_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											367.85	25						327.20	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
H5521	607	0	1	04	01	H5521_607_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	607	0	1	04	01	H5521_607_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	607	0	1	04	01	H5521_607_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.34	22	22	22				40.47	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	607	0	1	04	01	H5521_607_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.05	25	25	25				43.89	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	607	0	1	04	01	H5521_607_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											347.13	25						306.35	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
H5521	609	0	1	04	01	H5521_609_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	609	0	1	04	01	H5521_609_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5521	609	0	1	04	01	H5521_609_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.88	25	25	25				104.41	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	609	0	1	04	01	H5521_609_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.58	26	26	26				35.66	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	609	0	1	04	01	H5521_609_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1017.68	30						961.48	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
H5521	614	0	1	04	01	H5521_614_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	614	0	1	04	01	H5521_614_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	614	0	1	04	01	H5521_614_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.79	22	22	22				39.73	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	614	0	1	04	01	H5521_614_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.30	25	25	25				42.16	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	614	0	1	04	01	H5521_614_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											342.23	25						299.98	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
H5521	644	0	1	04	01	H5521_644_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	644	0	1	04	01	H5521_644_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	644	0	1	04	01	H5521_644_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.46	22	22	22				90.84	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	644	0	1	04	01	H5521_644_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.18	25	25	25				40.18	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	644	0	1	04	01	H5521_644_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											778.26	27						766.22	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	645	0	1	04	01	H5521_645_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	645	0	1	04	01	H5521_645_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	645	0	1	04	01	H5521_645_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.61	22	22	22				38.05	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	645	0	1	04	01	H5521_645_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.54	25	25	25				42.18	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	645	0	1	04	01	H5521_645_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											334.57	25						300.11	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
H5521	646	0	1	04	01	H5521_646_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	646	0	1	04	01	H5521_646_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	646	0	1	04	01	H5521_646_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.96	24	24	24				99.90	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
H5521	646	0	1	04	01	H5521_646_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											42.65	25	25	25				39.29	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	646	0	1	04	01	H5521_646_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											726.15	25						711.30	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
H5521	648	0	1	04	01	H5521_648_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	648	0	1	04	01	H5521_648_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5521	648	0	1	04	01	H5521_648_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.32	22	22	22				41.93	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	648	0	1	04	01	H5521_648_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.01	25	25	25				45.99	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
H5521	648	0	1	04	01	H5521_648_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											359.16	25						313.91	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
H5522	001	0	1	04	01	H5522_001_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	001	0	1	04	01	H5522_001_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	001	0	1	04	01	H5522_001_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.28	24	24	24				112.73	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
H5522	001	0	1	04	01	H5522_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.92	25	25	25				41.11	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	001	0	1	04	01	H5522_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											978.86	25						1012.67	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
H5522	002	0	1	04	01	H5522_002_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	002	0	1	04	01	H5522_002_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	002	0	1	04	01	H5522_002_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.51	24	24	24				112.31	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
H5522	002	0	1	04	01	H5522_002_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.90	25	25	25				39.33	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	002	0	1	04	01	H5522_002_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											984.75	25						782.49	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
H5522	004	0	1	04	01	H5522_004_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	004	0	1	04	01	H5522_004_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	004	0	1	04	01	H5522_004_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.09	24	24	24				115.13	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
H5522	004	0	1	04	01	H5522_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.56	25	25	25				42.34	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	004	0	1	04	01	H5522_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											812.04	25						936.76	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
H5522	005	0	1	04	01	H5522_005_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	005	0	1	04	01	H5522_005_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	005	0	1	04	01	H5522_005_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.70	24	24	24				109.56	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
H5522	005	0	1	04	01	H5522_005_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.54	25	25	25				41.05	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	005	0	1	04	01	H5522_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											654.45	25						807.91	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
H5522	013	0	1	04	01	H5522_013_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	013	0	1	04	01	H5522_013_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	013	0	1	04	01	H5522_013_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.46	24	24	24				111.82	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
H5522	013	0	1	04	01	H5522_013_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.44	25	25	25				45.13	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	013	0	1	04	01	H5522_013_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											620.63	25						734.59	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
H5522	014	0	1	04	01	H5522_014_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	014	0	1	04	01	H5522_014_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	014	0	1	04	01	H5522_014_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.67	24	24	24				109.40	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
H5522	014	0	1	04	01	H5522_014_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.18	25	25	25				43.30	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	014	0	1	04	01	H5522_014_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											804.88	25						622.46	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
H5522	017	0	1	04	01	H5522_017_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	017	0	1	04	01	H5522_017_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	017	0	1	04	01	H5522_017_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.88	24	24	24				114.44	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
H5522	017	0	1	04	01	H5522_017_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.44	25	25	25				38.87	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
H5522	017	0	1	04	01	H5522_017_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											923.83	25						907.42	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
H5522	022	0	1	04	01	H5522_022_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	022	0	1	04	01	H5522_022_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	022	0	1	04	01	H5522_022_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.59	24	24	24				113.81	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
H5522	022	0	1	04	01	H5522_022_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.32	25	25	25				40.39	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	022	0	1	04	01	H5522_022_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.69	25						862.54	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
H5522	028	0	1	04	01	H5522_028_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	028	0	1	04	01	H5522_028_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	028	0	1	04	01	H5522_028_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.10	24	24	24				115.82	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
H5522	028	0	1	04	01	H5522_028_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.69	25	25	25				36.58	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
H5522	028	0	1	04	01	H5522_028_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											862.32	25						829.99	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
H5522	029	0	1	04	01	H5522_029_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	029	0	1	04	01	H5522_029_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	029	0	1	04	01	H5522_029_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.75	24	24	24				112.04	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
H5522	029	0	1	04	01	H5522_029_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.02	25	25	25				38.48	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	029	0	1	04	01	H5522_029_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											806.01	25						784.01	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
H5522	032	0	1	04	01	H5522_032_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	032	0	1	04	01	H5522_032_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5522	032	0	1	04	01	H5522_032_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.79	22	22	22				44.48	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	032	0	1	04	01	H5522_032_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.01	25	25	25				45.81	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	032	0	1	04	01	H5522_032_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											380.12	25						333.92	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
H5525	004	0	1	04	01	H5525_004_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5525	004	0	1	04	01	H5525_004_0	3			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																								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
H5525	004	0	1	04	01	H5525_004_0	3			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	005	0	1	04	01	H5525_005_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
H5525	005	0	1	04	01	H5525_005_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
H5525	005	0	1	04	01	H5525_005_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		95.00	35.00		35.00
H5525	005	0	1	04	01	H5525_005_0	4			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																								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
H5525	005	0	1	04	01	H5525_005_0	4			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	006	0	1	04	01	H5525_006_0	4			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	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
H5525	006	0	1	04	01	H5525_006_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		95.00	35.00		35.00
H5525	006	0	1	04	01	H5525_006_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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
H5525	006	0	1	04	01	H5525_006_0	4			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	008	0	1	04	01	H5525_008_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
H5525	008	0	1	04	01	H5525_008_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
H5525	008	0	1	04	01	H5525_008_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		95.00	35.00		35.00
H5525	008	0	1	04	01	H5525_008_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5525	008	0	1	04	01	H5525_008_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
H5525	017	0	1	04	01	H5525_017_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
H5525	017	0	1	04	01	H5525_017_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
H5525	017	0	1	04	01	H5525_017_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		95.00	35.00		35.00
H5525	017	0	1	04	01	H5525_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H5525	017	0	1	04	01	H5525_017_0	4			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	024	0	1	04	01	H5525_024_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
H5525	024	0	1	04	01	H5525_024_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
H5525	024	0	1	04	01	H5525_024_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		95.00	35.00		35.00
H5525	024	0	1	04	01	H5525_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	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		35.00
H5525	024	0	1	04	01	H5525_024_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
H5525	026	0	1	04	01	H5525_026_0	4			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	4			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	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		95.00	35.00		35.00
H5525	026	0	1	04	01	H5525_026_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5525	026	0	1	04	01	H5525_026_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
H5525	027	0	1	04	01	H5525_027_0	3			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	3			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
H5525	027	0	1	04	01	H5525_027_0	3			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		95.00	35.00		35.00
H5525	027	0	1	04	01	H5525_027_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	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
H5525	027	0	1	04	01	H5525_027_0	3			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	030	0	1	04	01	H5525_030_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
H5525	030	0	1	04	01	H5525_030_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
H5525	030	0	1	04	01	H5525_030_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		95.00	35.00		35.00
H5525	030	0	1	04	01	H5525_030_0	4			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
H5525	030	0	1	04	01	H5525_030_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
H5525	034	0	1	04	01	H5525_034_0	4			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	4			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	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		95.00	35.00		35.00
H5525	034	0	1	04	01	H5525_034_0	4			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																								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
H5525	034	0	1	04	01	H5525_034_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
H5525	035	0	1	04	01	H5525_035_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
H5525	035	0	1	04	01	H5525_035_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
H5525	035	0	1	04	01	H5525_035_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		95.00	35.00		35.00
H5525	035	0	1	04	01	H5525_035_0	4			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																								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		35.00
H5525	035	0	1	04	01	H5525_035_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
H5525	041	0	1	04	01	H5525_041_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
H5525	041	0	1	04	01	H5525_041_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
H5525	041	0	1	04	01	H5525_041_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		95.00	35.00		35.00
H5525	041	0	1	04	01	H5525_041_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				86.00	39		39																								39		39				39		39			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
H5525	041	0	1	04	01	H5525_041_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
H5525	042	0	1	04	01	H5525_042_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
H5525	042	0	1	04	01	H5525_042_0	4			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	042	0	1	04	01	H5525_042_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		95.00	35.00		35.00
H5525	042	0	1	04	01	H5525_042_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				94.00	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		35.00
H5525	042	0	1	04	01	H5525_042_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
H5525	049	0	1	04	01	H5525_049_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
H5525	049	0	1	04	01	H5525_049_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
H5525	049	0	1	04	01	H5525_049_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		95.00	35.00		35.00
H5525	049	0	1	04	01	H5525_049_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H5525	049	0	1	04	01	H5525_049_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
H5525	050	0	1	04	01	H5525_050_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
H5525	050	0	1	04	01	H5525_050_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
H5525	050	0	1	04	01	H5525_050_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		95.00	35.00		35.00
H5525	050	0	1	04	01	H5525_050_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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
H5525	050	0	1	04	01	H5525_050_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
H5525	051	1	1	04	01	H5525_051_1	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
H5525	051	1	1	04	01	H5525_051_1	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
H5525	051	1	1	04	01	H5525_051_1	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		95.00	35.00		35.00
H5525	051	1	1	04	01	H5525_051_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5525	051	1	1	04	01	H5525_051_1	4			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	051	2	1	04	01	H5525_051_2	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
H5525	051	2	1	04	01	H5525_051_2	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
H5525	051	2	1	04	01	H5525_051_2	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		95.00	35.00		35.00
H5525	051	2	1	04	01	H5525_051_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5525	051	2	1	04	01	H5525_051_2	4			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	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
H5525	054	0	1	04	01	H5525_054_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
H5525	054	0	1	04	01	H5525_054_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		95.00	35.00		35.00
H5525	054	0	1	04	01	H5525_054_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	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		35.00
H5525	054	0	1	04	01	H5525_054_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
H5525	055	0	1	04	01	H5525_055_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
H5525	055	0	1	04	01	H5525_055_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
H5525	055	0	1	04	01	H5525_055_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		70.00	35.00		35.00
H5525	055	0	1	04	01	H5525_055_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5525	055	0	1	04	01	H5525_055_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
H5525	056	0	1	04	01	H5525_056_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
H5525	056	0	1	04	01	H5525_056_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
H5525	056	0	1	04	01	H5525_056_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		95.00	35.00		35.00
H5525	056	0	1	04	01	H5525_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5525	056	0	1	04	01	H5525_056_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
H5525	057	0	1	04	01	H5525_057_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
H5525	057	0	1	04	01	H5525_057_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
H5525	057	0	1	04	01	H5525_057_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		70.00	35.00		35.00
H5525	057	0	1	04	01	H5525_057_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5525	057	0	1	04	01	H5525_057_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
H5525	058	0	1	04	01	H5525_058_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
H5525	058	0	1	04	01	H5525_058_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
H5525	058	0	1	04	01	H5525_058_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		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		70.00	35.00		35.00
H5525	058	0	1	04	01	H5525_058_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				90.00	40		40																								42		42				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		35.00
H5525	058	0	1	04	01	H5525_058_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
H5525	059	0	1	04	01	H5525_059_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
H5525	059	0	1	04	01	H5525_059_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
H5525	059	0	1	04	01	H5525_059_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		95.00	35.00		35.00
H5525	059	0	1	04	01	H5525_059_0	4			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																								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
H5525	059	0	1	04	01	H5525_059_0	4			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	070	0	1	04	01	H5525_070_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																									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	4			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	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		95.00	35.00		35.00
H5525	070	0	1	04	01	H5525_070_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5525	070	0	1	04	01	H5525_070_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
H5525	074	0	1	04	01	H5525_074_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
H5525	074	0	1	04	01	H5525_074_0	4			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	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		70.00	35.00		35.00
H5525	074	0	1	04	01	H5525_074_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				73.00	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
H5525	074	0	1	04	01	H5525_074_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
H5525	075	0	1	04	01	H5525_075_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
H5525	075	0	1	04	01	H5525_075_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
H5525	075	0	1	04	01	H5525_075_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		70.00	35.00		35.00
H5525	075	0	1	04	01	H5525_075_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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
H5525	075	0	1	04	01	H5525_075_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
H5525	076	0	1	04	01	H5525_076_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
H5525	076	0	1	04	01	H5525_076_0	4			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	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		70.00	35.00		35.00
H5525	076	0	1	04	01	H5525_076_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	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
H5525	076	0	1	04	01	H5525_076_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
H5525	077	0	1	04	01	H5525_077_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
H5525	077	0	1	04	01	H5525_077_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
H5525	077	0	1	04	01	H5525_077_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		70.00	35.00		35.00
H5525	077	0	1	04	01	H5525_077_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5525	077	0	1	04	01	H5525_077_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
H5525	080	0	1	04	01	H5525_080_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
H5525	080	0	1	04	01	H5525_080_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
H5525	080	0	1	04	01	H5525_080_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		70.00	35.00		35.00
H5525	080	0	1	04	01	H5525_080_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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
H5525	080	0	1	04	01	H5525_080_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
H5525	083	0	1	04	01	H5525_083_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
H5525	083	0	1	04	01	H5525_083_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
H5525	083	0	1	04	01	H5525_083_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		95.00	35.00		35.00
H5525	083	0	1	04	01	H5525_083_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5525	083	0	1	04	01	H5525_083_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
H5525	084	0	1	04	01	H5525_084_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
H5525	084	0	1	04	01	H5525_084_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
H5525	084	0	1	04	01	H5525_084_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		70.00	35.00		35.00
H5525	084	0	1	04	01	H5525_084_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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
H5525	084	0	1	04	01	H5525_084_0	4			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
H5526	004	0	1	04	01	H5526_004_0	5			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													17.50						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5526	004	0	1	04	01	H5526_004_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								13.00		39.00					8.00		24.00													32.50						20.00				13.00				13.00			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	5			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													117.50						105.00				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
H5526	004	0	1	04	01	H5526_004_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								99.00		297.00					94.00		282.00													247.50						235.00				99.00				99.00			3.19	3.03				3.19	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
H5526	004	0	1	04	01	H5526_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5526	016	0	1	04	01	H5526_016_0	5			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								9.00		27.00					4.00		12.00													22.50						0.00				9.00				9.00			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	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					10.00		30.00													37.50						25.00				15.00				15.00			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	5			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													117.50						105.00				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
H5526	016	0	1	04	01	H5526_016_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					94.00		282.00													250.00						235.00				100.00				100.00			3.23	3.03				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
H5526	016	0	1	04	01	H5526_016_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5526	018	0	1	04	01	H5526_018_0	5			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					2.00		6.00													17.50						0.00				7.00				7.00			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	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					10.00		30.00													37.50						25.00				15.00				15.00			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											96.61	25		25				102.85	25		25												25						25			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
H5526	018	0	1	04	01	H5526_018_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											63.58	39		39				44.65	39		39												39						39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H5526	018	0	1	04	01	H5526_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5526	020	0	1	04	01	H5526_020_0	5			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													12.50						0.00				5.00				5.00			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	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								17.00		51.00					5.00		15.00													42.50						0.00				17.00				17.00			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											109.01	25		25				108.86	25		25												25						25			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
H5526	020	0	1	04	01	H5526_020_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											59.05	49		49				46.54	49		49												49						49			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
H5526	020	0	1	04	01	H5526_020_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5526	027	0	1	04	01	H5526_027_0	5			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													12.50						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5526	027	0	1	04	01	H5526_027_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								17.00		51.00					0.00		0.00													42.50						0.00				17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5526	027	0	1	04	01	H5526_027_0	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											109.05	25		25				109.03	25		25												25						25			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
H5526	027	0	1	04	01	H5526_027_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											59.64	50		50				47.34	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
H5526	027	0	1	04	01	H5526_027_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								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		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				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	003	0	1	04	01	H5533_003_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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	003	0	1	04	01	H5533_003_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	003	0	1	04	01	H5533_003_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											82.54	50	50	50				101.24	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
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											1293.12	31						1130.35	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	005	0	1	04	01	H5533_005_0	9			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	005	0	1	04	01	H5533_005_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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	005	0	1	04	01	H5533_005_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	005	0	1	04	01	H5533_005_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											91.12	50	50	50				105.08	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	005	0	1	04	01	H5533_005_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1358.99	33						1418.45	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		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				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	008	0	1	04	01	H5533_008_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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	008	0	1	04	01	H5533_008_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	008	0	1	04	01	H5533_008_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											99.47	45	45	45				100.44	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
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											922.00	31						1010.71	31												31						31					31			31								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		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				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	011	0	1	04	01	H5533_011_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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	011	0	1	04	01	H5533_011_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	011	0	1	04	01	H5533_011_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											99.11	39	39	39				81.86	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
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											1078.03	28						1258.50	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	013	0	1	04	01	H5533_013_0	12			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	013	0	1	04	01	H5533_013_0	12			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				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	013	0	1	04	01	H5533_013_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	013	0	1	04	01	H5533_013_0	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.52	47	47	47				104.57	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	013	0	1	04	01	H5533_013_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											914.02	28						1174.74	28												28						28					28			28								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		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				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	015	1	1	04	01	H5533_015_1	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	015	1	1	04	01	H5533_015_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	1	1	04	01	H5533_015_1	11			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				93.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
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											1030.13	31						1052.76	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	015	2	1	04	01	H5533_015_2	12			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	015	2	1	04	01	H5533_015_2	12			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				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	015	2	1	04	01	H5533_015_2	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	2	1	04	01	H5533_015_2	12			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				93.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	2	1	04	01	H5533_015_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1030.13	31						1052.76	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	015	3	1	04	01	H5533_015_3	12			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	015	3	1	04	01	H5533_015_3	12			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				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	015	3	1	04	01	H5533_015_3	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	3	1	04	01	H5533_015_3	12			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				93.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	3	1	04	01	H5533_015_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1030.13	31						1052.76	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	015	4	1	04	01	H5533_015_4	12			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	015	4	1	04	01	H5533_015_4	12			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				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	015	4	1	04	01	H5533_015_4	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	4	1	04	01	H5533_015_4	12			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				93.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	4	1	04	01	H5533_015_4	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1030.13	31						1052.76	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	015	5	1	04	01	H5533_015_5	12			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	015	5	1	04	01	H5533_015_5	12			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				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	015	5	1	04	01	H5533_015_5	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	5	1	04	01	H5533_015_5	12			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				93.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	015	5	1	04	01	H5533_015_5	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1030.13	31						1052.76	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	017	1	1	04	01	H5533_017_1	10			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	017	1	1	04	01	H5533_017_1	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	017	1	1	04	01	H5533_017_1	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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	017	1	1	04	01	H5533_017_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											80.50	50	50	50				85.14	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	017	1	1	04	01	H5533_017_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1015.92	28						1132.88	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5533	017	2	1	04	01	H5533_017_2	10			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	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.5	0.00	0.00	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		0.00
H5533	017	2	1	04	01	H5533_017_2	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	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				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	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		0.00
H5533	017	2	1	04	01	H5533_017_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	129.50											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										35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	017	2	1	04	01	H5533_017_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											80.50	50	50	50				85.14	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H5533	017	2	1	04	01	H5533_017_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1015.92	28						1132.88	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5549	012	0	1	01	01	H5549_012_0	5			Preferred Generic	4	01	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 Brand, Specialty Tier, Select Care Drugs										0.00	0.00	0.00						0.00				0.00		0.00
H5549	012	0	1	01	01	H5549_012_0	5			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	5			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	5			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	5			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	5			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	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	005	0	1	01	01	H5577_005_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	005	0	1	01	01	H5577_005_0	5			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	5			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	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				333.86	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5577	005	0	1	01	01	H5577_005_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			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			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			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				322.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
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	038	0	1	01	01	H5577_038_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	038	0	1	01	01	H5577_038_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	038	0	1	01	01	H5577_038_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	038	0	1	01	01	H5577_038_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	038	0	1	01	01	H5577_038_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				202.34	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5577	038	0	1	01	01	H5577_038_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	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			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			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				223.30	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
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	043	0	1	01	01	H5577_043_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	043	0	1	01	01	H5577_043_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	043	0	1	01	01	H5577_043_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	043	0	1	01	01	H5577_043_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	043	0	1	01	01	H5577_043_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				297.43	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5577	043	0	1	01	01	H5577_043_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	044	0	1	01	01	H5577_044_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	044	0	1	01	01	H5577_044_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	044	0	1	01	01	H5577_044_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	044	0	1	01	01	H5577_044_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	044	0	1	01	01	H5577_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				451.90	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5577	044	0	1	01	01	H5577_044_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			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			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			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				380.41	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
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	052	0	1	01	01	H5577_052_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	052	0	1	01	01	H5577_052_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	052	0	1	01	01	H5577_052_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	052	0	1	01	01	H5577_052_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	052	0	1	01	01	H5577_052_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				268.68	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5577	052	0	1	01	01	H5577_052_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			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			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			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	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	053	0	1	01	01	H5577_053_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				186.01	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
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	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			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			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				312.68	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
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	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			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			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				312.68	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
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	057	0	1	01	01	H5577_057_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	057	0	1	01	01	H5577_057_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	057	0	1	01	01	H5577_057_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	057	0	1	01	01	H5577_057_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	057	0	1	01	01	H5577_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				289.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5577	057	0	1	01	01	H5577_057_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	059	0	1	01	01	H5577_059_0	8			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	059	0	1	01	01	H5577_059_0	8			Generic	4	01	3	2	2	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	059	0	1	01	01	H5577_059_0	8			Preferred Brand	4	10	1	2	3	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	059	0	1	01	01	H5577_059_0	8			Non-Preferred Brand	4	10	1	2	4	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	059	0	1	01	01	H5577_059_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				301.16	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5577	059	0	1	01	01	H5577_059_0	8			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
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					42.00	84.00	126.00					47.00	94.00	117.50																47.00				47.00			1.57	1.40	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											296.01	33						147.88	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	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					42.00	84.00	126.00					47.00	94.00	117.50																47.00				47.00			1.57	1.40	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											306.97	33						182.98	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	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					42.00	84.00	126.00					47.00	94.00	117.50																47.00				47.00			1.57	1.40	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											306.97	33						182.98	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	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								10.00	20.00	30.00					0.00	0.00	0.00					10.00	20.00	25.00																10.00				10.00			0.33	0.00	0.33			0.32	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					42.00	84.00	126.00					47.00	94.00	117.50																47.00				47.00			1.57	1.40	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-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											285.16	31						178.36	31						31																	31			31								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					42.00	84.00	126.00					47.00	94.00	117.50																47.00				47.00			1.57	1.40	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											218.97	33						171.28	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	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					42.00	84.00	126.00					47.00	94.00	117.50																47.00				47.00			1.57	1.40	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											218.97	33						171.28	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																								
H5594	001	0	1	01	01	H5594_001_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			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	0.00	0.00	0.00				0.00		0.00
H5594	001	0	1	01	01	H5594_001_0	7			Preferred Brand	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	10.00	10.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										5.00	10.00	15.00	5.00	10.00	15.00	5.00	10.00	10.00				5.00		5.00
H5594	001	0	1	01	01	H5594_001_0	7			Non-Preferred Drug	4	11	3	2	3	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	30.00	30.00																20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										20.00	40.00	60.00	15.00	30.00	45.00	15.00	30.00	30.00				20.00		20.00
H5594	001	0	1	01	01	H5594_001_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	002	0	1	01	01	H5594_002_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			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	0.00	0.00	0.00				0.00		0.00
H5594	002	0	1	01	01	H5594_002_0	7			Preferred Brand	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	10.00	10.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										5.00	10.00	15.00	5.00	10.00	15.00	5.00	10.00	10.00				5.00		5.00
H5594	002	0	1	01	01	H5594_002_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								55.00	110.00	165.00					50.00	100.00	150.00					50.00	100.00	100.00																55.00				55.00			1.83	1.67	1.67			1.62	Preferred 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
H5594	002	0	1	01	01	H5594_002_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	016	0	1	01	01	H5594_016_0	11		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				2.40	24	24	24																		24	24	24															24			24								Preferred 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
H5594	016	0	1	01	01	H5594_016_0	11		N	Preferred Brand	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				75.86	25	25	25																		25	25	25															25			25								Preferred 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
H5594	016	0	1	01	01	H5594_016_0	11		N	Non-Preferred Drug	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				70.99	25	25	25																		25	25	25															25			25								Preferred 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
H5594	016	0	1	01	01	H5594_016_0	11		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, Supplemental Drugs																								
H5594	016	0	1	01	01	H5594_016_0	11		N	Supplemental Drugs	4	11	2	2	5	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5594	017	0	1	01	01	H5594_017_0	7		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				2.45	24	24	24																		24	24	24															24			24								Preferred 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
H5594	017	0	1	01	01	H5594_017_0	7		N	Preferred Brand	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				79.72	25	25	25																		25	25	25															25			25								Preferred 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
H5594	017	0	1	01	01	H5594_017_0	7		N	Non-Preferred Drug	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				73.03	25	25	25																		25	25	25															25			25								Preferred 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
H5594	017	0	1	01	01	H5594_017_0	7		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, Supplemental Drugs																								
H5594	017	0	1	01	01	H5594_017_0	7		N	Supplemental Drugs	4	11	2	2	5	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																								
H5594	019	0	1	01	01	H5594_019_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			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	0.00	0.00	0.00				0.00		0.00
H5594	019	0	1	01	01	H5594_019_0	8			Preferred Brand	4	11	3	2	2	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	94.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred 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
H5594	019	0	1	01	01	H5594_019_0	8			Non-Preferred Drug	4	11	3	2	3	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, Preferred Brand, Non-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
H5594	019	0	1	01	01	H5594_019_0	8			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	022	0	1	01	01	H5594_022_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			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	0.00	0.00	0.00				0.00		0.00
H5594	022	0	1	01	01	H5594_022_0	8			Preferred Brand	4	11	3	2	2	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	94.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred 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
H5594	022	0	1	01	01	H5594_022_0	8			Non-Preferred Drug	4	11	3	2	3	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, Preferred Brand, Non-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
H5594	022	0	1	01	01	H5594_022_0	8			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	026	0	1	01	01	H5594_026_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			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	0.00	0.00	0.00				0.00		0.00
H5594	026	0	1	01	01	H5594_026_0	9			Preferred Brand	4	11	3	2	2	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	94.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred 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
H5594	026	0	1	01	01	H5594_026_0	9			Non-Preferred Drug	4	11	3	2	3	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, Preferred Brand, Non-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
H5594	026	0	1	01	01	H5594_026_0	9			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	028	0	1	01	01	H5594_028_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			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	0.00	0.00	0.00				0.00		0.00
H5594	028	0	1	01	01	H5594_028_0	10			Preferred Brand	4	11	3	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	30.00	30.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5594	028	0	1	01	01	H5594_028_0	10			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								60.00	120.00	180.00					55.00	110.00	165.00					55.00	110.00	110.00																60.00				60.00			2.00	1.83	1.83			1.76	Preferred 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		35.00
H5594	028	0	1	01	01	H5594_028_0	10			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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	10			Select Diabetic Drugs	4	11	1	2	5	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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5594	029	0	1	01	01	H5594_029_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			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	0.00	0.00	0.00				0.00		0.00
H5594	029	0	1	01	01	H5594_029_0	7			Preferred Brand	4	11	3	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	30.00	30.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	30.00	45.00	15.00	30.00	45.00	15.00	30.00	30.00				15.00		15.00
H5594	029	0	1	01	01	H5594_029_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								60.00	120.00	180.00					55.00	110.00	165.00					55.00	110.00	110.00																60.00				60.00			2.00	1.83	1.83			1.76	Preferred Generic, Preferred Brand, Non-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
H5594	029	0	1	01	01	H5594_029_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	030	0	1	01	01	H5594_030_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			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	0.00	0.00	0.00				0.00		0.00
H5594	030	0	1	01	01	H5594_030_0	7			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5594	030	0	1	01	01	H5594_030_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred 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		35.00
H5594	030	0	1	01	01	H5594_030_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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	7			Select Diabetic Drugs	4	11	1	2	5	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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5594	031	0	1	01	01	H5594_031_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			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	0.00	0.00	0.00				0.00		0.00
H5594	031	0	1	01	01	H5594_031_0	7			Preferred Brand	4	11	3	2	2	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, 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
H5594	031	0	1	01	01	H5594_031_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Preferred Brand, Non-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
H5594	031	0	1	01	01	H5594_031_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	032	0	1	01	01	H5594_032_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			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	0.00	0.00	0.00				0.00		0.00
H5594	032	0	1	01	01	H5594_032_0	8			Preferred Brand	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	10.00	10.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										5.00	10.00	15.00	5.00	10.00	15.00	5.00	10.00	10.00				5.00		5.00
H5594	032	0	1	01	01	H5594_032_0	8			Non-Preferred Drug	4	11	3	2	3	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	30.00	30.00																20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										20.00	40.00	60.00	15.00	30.00	45.00	15.00	30.00	30.00				20.00		20.00
H5594	032	0	1	01	01	H5594_032_0	8			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	034	0	1	01	01	H5594_034_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			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	0.00	0.00	0.00				0.00		0.00
H5594	034	0	1	01	01	H5594_034_0	7			Preferred Brand	4	11	3	2	2	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, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5594	034	0	1	01	01	H5594_034_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred 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		35.00
H5594	034	0	1	01	01	H5594_034_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5594	034	0	1	01	01	H5594_034_0	7			Select Diabetic Drugs	4	11	1	2	5	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					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H5594	035	0	1	01	01	H5594_035_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			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	0.00	0.00	0.00				0.00		0.00
H5594	035	0	1	01	01	H5594_035_0	7			Preferred Brand	4	11	3	2	2	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, 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
H5594	035	0	1	01	01	H5594_035_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								90.00	180.00	270.00					85.00	170.00	255.00					85.00	170.00	170.00																90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Preferred Brand, Non-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
H5594	035	0	1	01	01	H5594_035_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5594	036	0	1	01	01	H5594_036_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			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	0.00	0.00	0.00				0.00		0.00
H5594	036	0	1	01	01	H5594_036_0	7			Preferred Brand	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	10.00	10.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																								
H5594	036	0	1	01	01	H5594_036_0	7			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								55.00	110.00	165.00					50.00	100.00	150.00					50.00	100.00	100.00																55.00				55.00			1.83	1.67	1.67			1.62	Preferred 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	100.00				35.00		35.00
H5594	036	0	1	01	01	H5594_036_0	7			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							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	7			Select Diabetic Drugs	4	11	1	2	5	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, 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				0.00		0.00
H5599	002	0	1	02	01	H5599_002_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					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5599	002	0	1	02	01	H5599_002_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5599	002	0	1	02	01	H5599_002_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											134.51	23	23	23				134.51	23	23	23										23	23	23				23	23	23			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
H5599	002	0	1	02	01	H5599_002_0	5			Non-Preferred Drug	3	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	200.00				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
H5599	002	0	1	02	01	H5599_002_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																								
H5599	002	0	1	02	01	H5599_002_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																								
H5599	004	0	1	02	01	H5599_004_0	5			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	02	01	H5599_004_0	5			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																								
H5599	004	0	1	02	01	H5599_004_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.09	25	25	25				153.09	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
H5599	004	0	1	02	01	H5599_004_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											53.35	45	45	45				53.35	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
H5599	004	0	1	02	01	H5599_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, Select Care Drugs																								
H5599	004	0	1	02	01	H5599_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		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			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	4			Preferred Generic	4	01	1	2	1	1		111	10		100	1				30	60	100	1	2						100		10	31								15.00	30.00	45.00					0.00	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 Brand, Specialty Tier, Select Care Drugs										15.00	30.00	45.00	0.00	0.00	0.00			45.00			0.00	15.00		15.00
H5608	002	0	1	01	01	H5608_002_0	4			Generic	4	01	1	2	2	1		111	10		100	1				30	60	100	1	2						100		10	31								20.00	40.00	60.00					9.00	18.00	18.00													60.00						0.00					20.00			20.00			0.67	0.30				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										20.00	40.00	60.00	9.00	18.00	18.00			60.00			0.00	20.00		20.00
H5608	002	0	1	01	01	H5608_002_0	4			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					45.00	90.00	135.00													141.00						135.00					47.00			47.00			1.57	1.50				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			105.00			105.00	35.00		35.00
H5608	002	0	1	01	01	H5608_002_0	4			Non-Preferred Brand	4	10	1	2	4	1		111	10		100	1				30	60	100	1	2						100		10	31								100.00	200.00	300.00					95.00	190.00	285.00													300.00						285.00					100.00			100.00			3.33	3.17				3.23	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			105.00			105.00	35.00		35.00
H5608	002	0	1	01	01	H5608_002_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											598.13	33						318.70	33												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			35.00		35.00
H5608	002	0	1	01	01	H5608_002_0	4			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					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	0.00		0.00
H5619	001	0	1	01	01	H5619_001_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
H5619	001	0	1	01	01	H5619_001_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
H5619	001	0	1	01	01	H5619_001_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		95.00	35.00		35.00
H5619	001	0	1	01	01	H5619_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	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		35.00
H5619	001	0	1	01	01	H5619_001_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
H5619	012	0	1	01	01	H5619_012_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	012	0	1	01	01	H5619_012_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
H5619	012	0	1	01	01	H5619_012_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		95.00	35.00		35.00
H5619	012	0	1	01	01	H5619_012_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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
H5619	012	0	1	01	01	H5619_012_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	015	0	1	01	01	H5619_015_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	015	0	1	01	01	H5619_015_0	4			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	015	0	1	01	01	H5619_015_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		95.00	35.00		35.00
H5619	015	0	1	01	01	H5619_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H5619	015	0	1	01	01	H5619_015_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	016	0	1	01	01	H5619_016_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	016	0	1	01	01	H5619_016_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	016	0	1	01	01	H5619_016_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		95.00	35.00		35.00
H5619	016	0	1	01	01	H5619_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H5619	016	0	1	01	01	H5619_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 Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5619	021	0	1	01	01	H5619_021_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	021	0	1	01	01	H5619_021_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	021	0	1	01	01	H5619_021_0	4			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		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		70.00	35.00		35.00
H5619	021	0	1	01	01	H5619_021_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	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		35.00
H5619	021	0	1	01	01	H5619_021_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	026	0	1	01	01	H5619_026_0	4			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	4			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	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		95.00	35.00		35.00
H5619	026	0	1	01	01	H5619_026_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H5619	026	0	1	01	01	H5619_026_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
H5619	046	0	1	01	01	H5619_046_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
H5619	046	0	1	01	01	H5619_046_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
H5619	046	0	1	01	01	H5619_046_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		95.00	35.00		35.00
H5619	046	0	1	01	01	H5619_046_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				90.00	37		37																								37		37				37		37			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
H5619	046	0	1	01	01	H5619_046_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
H5619	047	0	1	01	01	H5619_047_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
H5619	047	0	1	01	01	H5619_047_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
H5619	047	0	1	01	01	H5619_047_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		95.00	35.00		35.00
H5619	047	0	1	01	01	H5619_047_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		35.00
H5619	047	0	1	01	01	H5619_047_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
H5619	049	0	1	02	01	H5619_049_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
H5619	049	0	1	02	01	H5619_049_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
H5619	049	0	1	02	01	H5619_049_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		95.00	35.00		35.00
H5619	049	0	1	02	01	H5619_049_0	4			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																								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
H5619	049	0	1	02	01	H5619_049_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	051	0	1	02	01	H5619_051_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
H5619	051	0	1	02	01	H5619_051_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
H5619	051	0	1	02	01	H5619_051_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		95.00	35.00		35.00
H5619	051	0	1	02	01	H5619_051_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5619	051	0	1	02	01	H5619_051_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	053	0	1	02	01	H5619_053_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
H5619	053	0	1	02	01	H5619_053_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
H5619	053	0	1	02	01	H5619_053_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		95.00	35.00		35.00
H5619	053	0	1	02	01	H5619_053_0	4			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																								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
H5619	053	0	1	02	01	H5619_053_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	055	0	1	01	01	H5619_055_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, 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	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, 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	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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5619	055	0	1	01	01	H5619_055_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				94.00	43		43																								43		43				43		43			43			43								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	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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5619	055	0	1	01	01	H5619_055_0	4			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	3			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	3			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	3			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		95.00	35.00		35.00
H5619	056	0	1	01	01	H5619_056_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	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
H5619	056	0	1	01	01	H5619_056_0	3			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	057	0	1	01	01	H5619_057_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	057	0	1	01	01	H5619_057_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
H5619	057	0	1	01	01	H5619_057_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		95.00	35.00		35.00
H5619	057	0	1	01	01	H5619_057_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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
H5619	057	0	1	01	01	H5619_057_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	059	0	1	01	01	H5619_059_0	3			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	3			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	059	0	1	01	01	H5619_059_0	3			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		95.00	35.00		35.00
H5619	059	0	1	01	01	H5619_059_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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
H5619	059	0	1	01	01	H5619_059_0	3			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	061	0	1	01	01	H5619_061_0	3			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	3			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	061	0	1	01	01	H5619_061_0	3			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		95.00	35.00		35.00
H5619	061	0	1	01	01	H5619_061_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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
H5619	061	0	1	01	01	H5619_061_0	3			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										35.00						35.00			35.00			35.00		35.00
H5619	063	0	1	01	01	H5619_063_0	3			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	3			Generic	4	11	3	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
H5619	063	0	1	01	01	H5619_063_0	3			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		95.00	35.00		35.00
H5619	063	0	1	01	01	H5619_063_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5619	063	0	1	01	01	H5619_063_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										35.00						35.00			35.00			35.00		35.00
H5619	066	0	1	01	01	H5619_066_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
H5619	066	0	1	01	01	H5619_066_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
H5619	066	0	1	01	01	H5619_066_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		95.00	35.00		35.00
H5619	066	0	1	01	01	H5619_066_0	4			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																								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		35.00
H5619	066	0	1	01	01	H5619_066_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
H5619	069	0	1	02	01	H5619_069_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
H5619	069	0	1	02	01	H5619_069_0	4			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	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		95.00	35.00		35.00
H5619	069	0	1	02	01	H5619_069_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				72.00	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
H5619	069	0	1	02	01	H5619_069_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	071	0	1	01	01	H5619_071_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
H5619	071	0	1	01	01	H5619_071_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
H5619	071	0	1	01	01	H5619_071_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		95.00	35.00		35.00
H5619	071	0	1	01	01	H5619_071_0	4			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																								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
H5619	071	0	1	01	01	H5619_071_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	077	0	1	01	01	H5619_077_0	3			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	3			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
H5619	077	0	1	01	01	H5619_077_0	3			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		95.00	35.00		35.00
H5619	077	0	1	01	01	H5619_077_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H5619	077	0	1	01	01	H5619_077_0	3			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	083	0	1	01	01	H5619_083_0	4			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	4			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	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		95.00	35.00		35.00
H5619	083	0	1	01	01	H5619_083_0	4			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																								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		35.00
H5619	083	0	1	01	01	H5619_083_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
H5619	089	0	1	01	01	H5619_089_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	089	0	1	01	01	H5619_089_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
H5619	089	0	1	01	01	H5619_089_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		95.00	35.00		35.00
H5619	089	0	1	01	01	H5619_089_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H5619	089	0	1	01	01	H5619_089_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
H5619	090	0	1	01	01	H5619_090_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	090	0	1	01	01	H5619_090_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	090	0	1	01	01	H5619_090_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		95.00	35.00		35.00
H5619	090	0	1	01	01	H5619_090_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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
H5619	090	0	1	01	01	H5619_090_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	091	0	1	01	01	H5619_091_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	091	0	1	01	01	H5619_091_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	091	0	1	01	01	H5619_091_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		95.00	35.00		35.00
H5619	091	0	1	01	01	H5619_091_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5619	091	0	1	01	01	H5619_091_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
H5619	095	0	1	01	01	H5619_095_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	095	0	1	01	01	H5619_095_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
H5619	095	0	1	01	01	H5619_095_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		95.00	35.00		35.00
H5619	095	0	1	01	01	H5619_095_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5619	095	0	1	01	01	H5619_095_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
H5619	100	0	1	01	01	H5619_100_0	3			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	3			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	3			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		95.00	35.00		35.00
H5619	100	0	1	01	01	H5619_100_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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
H5619	100	0	1	01	01	H5619_100_0	3			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	111	0	1	02	01	H5619_111_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
H5619	111	0	1	02	01	H5619_111_0	4			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	111	0	1	02	01	H5619_111_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		95.00	35.00		35.00
H5619	111	0	1	02	01	H5619_111_0	4			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																								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
H5619	111	0	1	02	01	H5619_111_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	113	0	1	02	01	H5619_113_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
H5619	113	0	1	02	01	H5619_113_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
H5619	113	0	1	02	01	H5619_113_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		95.00	35.00		35.00
H5619	113	0	1	02	01	H5619_113_0	4			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																								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
H5619	113	0	1	02	01	H5619_113_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	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	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	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		70.00	35.00		35.00
H5619	116	0	1	01	01	H5619_116_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		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	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	119	0	1	01	01	H5619_119_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	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		70.00	35.00		35.00
H5619	119	0	1	01	01	H5619_119_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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
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	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
H5619	122	0	1	01	01	H5619_122_0	4			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	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		95.00	35.00		35.00
H5619	122	0	1	01	01	H5619_122_0	4			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																								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
H5619	122	0	1	01	01	H5619_122_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	130	1	1	01	01	H5619_130_1	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	130	1	1	01	01	H5619_130_1	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	130	1	1	01	01	H5619_130_1	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		95.00	35.00		35.00
H5619	130	1	1	01	01	H5619_130_1	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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
H5619	130	1	1	01	01	H5619_130_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
H5619	130	2	1	01	01	H5619_130_2	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	130	2	1	01	01	H5619_130_2	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	130	2	1	01	01	H5619_130_2	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		95.00	35.00		35.00
H5619	130	2	1	01	01	H5619_130_2	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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
H5619	130	2	1	01	01	H5619_130_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
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		95.00	35.00		35.00
H5619	131	0	1	01	01	H5619_131_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		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	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	133	0	1	01	01	H5619_133_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	133	0	1	01	01	H5619_133_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		95.00	35.00		35.00
H5619	133	0	1	01	01	H5619_133_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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		35.00
H5619	133	0	1	01	01	H5619_133_0	4			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	4			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	4			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	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		95.00	35.00		35.00
H5619	135	0	1	01	01	H5619_135_0	4			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																								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
H5619	135	0	1	01	01	H5619_135_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
H5619	137	0	1	01	01	H5619_137_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
H5619	137	0	1	01	01	H5619_137_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
H5619	137	0	1	01	01	H5619_137_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		95.00	35.00		35.00
H5619	137	0	1	01	01	H5619_137_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				90.00	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
H5619	137	0	1	01	01	H5619_137_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
H5619	143	0	1	01	01	H5619_143_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	143	0	1	01	01	H5619_143_0	4			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
H5619	143	0	1	01	01	H5619_143_0	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		95.00	35.00		35.00
H5619	143	0	1	01	01	H5619_143_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	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
H5619	143	0	1	01	01	H5619_143_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	145	0	1	01	01	H5619_145_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
H5619	145	0	1	01	01	H5619_145_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
H5619	145	0	1	01	01	H5619_145_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		95.00	35.00		35.00
H5619	145	0	1	01	01	H5619_145_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		105.00	35.00		35.00
H5619	145	0	1	01	01	H5619_145_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
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			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	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	34.00		102.00																									47.00		141.00				34.00		68.00				34.00				34.00		1.13				1.57	1.13	1.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				35.00		105.00	34.00		68.00	34.00		34.00
H5619	146	0	1	01	01	H5619_146_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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
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	5.00		15.00																									20.00		60.00				5.00		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	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		70.00	35.00		35.00
H5619	147	0	1	01	01	H5619_147_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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
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		95.00	35.00		35.00
H5619	148	0	1	01	01	H5619_148_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				89.00	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
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	30.00		90.00																									47.00		141.00				30.00		60.00				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		60.00	30.00		30.00
H5619	150	0	1	01	01	H5619_150_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				56.00	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		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	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
H5619	152	0	1	01	01	H5619_152_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										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	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		95.00	35.00		35.00
H5619	152	0	1	01	01	H5619_152_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H5619	152	0	1	01	01	H5619_152_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
H5619	154	0	1	01	01	H5619_154_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, Select Care Drugs										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	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, Select Care Drugs										10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5619	154	0	1	01	01	H5619_154_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H5619	154	0	1	01	01	H5619_154_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				99.00	43		43																								43		43				43		43			43			43								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	154	0	1	01	01	H5619_154_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H5619	154	0	1	01	01	H5619_154_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				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	157	0	1	01	01	H5619_157_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
H5619	157	0	1	01	01	H5619_157_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
H5619	157	0	1	01	01	H5619_157_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		95.00	35.00		35.00
H5619	157	0	1	01	01	H5619_157_0	4			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																								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
H5619	157	0	1	01	01	H5619_157_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
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		70.00	35.00		35.00
H5619	159	0	1	01	01	H5619_159_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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
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	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				0.00		0.00	0.00		0.00	0.00		0.00
H5619	161	0	1	01	01	H5619_161_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										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	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										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	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	38		38																								38		38				38		38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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	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										0.00						0.00			0.00			0.00		0.00
H5619	164	0	1	01	01	H5619_164_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, 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	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, Select Care Drugs										5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	164	0	1	01	01	H5619_164_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		95.00	35.00		35.00
H5619	164	0	1	01	01	H5619_164_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	38		38																								38		38				38		38			38			38								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	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										35.00						35.00			35.00			35.00		35.00
H5619	164	0	1	01	01	H5619_164_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																									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
H5619	169	0	1	01	01	H5619_169_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
H5619	169	0	1	01	01	H5619_169_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
H5619	169	0	1	01	01	H5619_169_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		95.00	35.00		35.00
H5619	169	0	1	01	01	H5619_169_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H5619	169	0	1	01	01	H5619_169_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
H5619	170	0	1	01	01	H5619_170_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	170	0	1	01	01	H5619_170_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	170	0	1	01	01	H5619_170_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		95.00	35.00		35.00
H5619	170	0	1	01	01	H5619_170_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				81.00	44		44																								44		44				44		44			44			44								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	170	0	1	01	01	H5619_170_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	170	0	1	01	01	H5619_170_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
H5619	171	0	1	01	01	H5619_171_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
H5619	171	0	1	01	01	H5619_171_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
H5619	171	0	1	01	01	H5619_171_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		95.00	35.00		35.00
H5619	171	0	1	01	01	H5619_171_0	4			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																								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		35.00
H5619	171	0	1	01	01	H5619_171_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
H5619	172	0	1	01	01	H5619_172_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
H5619	172	0	1	01	01	H5619_172_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
H5619	172	0	1	01	01	H5619_172_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		95.00	35.00		35.00
H5619	172	0	1	01	01	H5619_172_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				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		35.00
H5619	172	0	1	01	01	H5619_172_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
H5619	173	0	1	01	01	H5619_173_0	3			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	173	0	1	01	01	H5619_173_0	3			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	173	0	1	01	01	H5619_173_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5619	173	0	1	01	01	H5619_173_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	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		35.00
H5619	173	0	1	01	01	H5619_173_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										35.00						35.00			35.00			35.00		35.00
H5619	174	0	1	01	01	H5619_174_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	174	0	1	01	01	H5619_174_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	174	0	1	01	01	H5619_174_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		95.00	35.00		35.00
H5619	174	0	1	01	01	H5619_174_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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
H5619	174	0	1	01	01	H5619_174_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	175	0	1	01	01	H5619_175_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	175	0	1	01	01	H5619_175_0	4			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	175	0	1	01	01	H5619_175_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		95.00	35.00		35.00
H5619	175	0	1	01	01	H5619_175_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
H5619	175	0	1	01	01	H5619_175_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	177	0	1	01	01	H5619_177_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	177	0	1	01	01	H5619_177_0	4			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
H5619	177	0	1	01	01	H5619_177_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		95.00	35.00		35.00
H5619	177	0	1	01	01	H5619_177_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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
H5619	177	0	1	01	01	H5619_177_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	178	0	1	01	01	H5619_178_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	178	0	1	01	01	H5619_178_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	178	0	1	01	01	H5619_178_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		70.00	35.00		35.00
H5619	178	0	1	01	01	H5619_178_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H5619	178	0	1	01	01	H5619_178_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
H5649	001	0	1	01	01	H5649_001_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	001	0	1	01	01	H5649_001_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	001	0	1	01	01	H5649_001_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																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	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H5649	001	0	1	01	01	H5649_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	75.00	150.00	150.00																			75.00	150.00	150.00																75.00				75.00		2.42			2.42			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	001	0	1	01	01	H5649_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				158.70	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
H5649	001	0	1	01	01	H5649_001_0	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	006	0	1	01	01	H5649_006_0	7			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	006	0	1	01	01	H5649_006_0	7			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	006	0	1	01	01	H5649_006_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																35.00				35.00		1.13			1.13			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
H5649	006	0	1	01	01	H5649_006_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	75.00	150.00	150.00																			75.00	150.00	150.00																75.00				75.00		2.42			2.42			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	31								31						31		31				85.98	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
H5649	006	0	1	01	01	H5649_006_0	7			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	008	0	1	01	01	H5649_008_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	008	0	1	01	01	H5649_008_0	8			Generic	4	11	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 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	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	94.00																			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	70.00				35.00	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	111		1	31	60	100				1	2	31	60	100				31		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.23			3.23			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	31								31						31		31				264.82	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
H5649	008	0	1	01	01	H5649_008_0	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	018	0	1	01	01	H5649_018_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	018	0	1	01	01	H5649_018_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	018	0	1	01	01	H5649_018_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																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	70.00	70.00				35.00	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	111		1	31	60	100				1	2	31	60	100				31		31	75.00	150.00	150.00																			75.00	150.00	150.00																75.00				75.00		2.42			2.42			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	31								31						31		31				160.03	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
H5649	018	0	1	01	01	H5649_018_0	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	019	0	1	01	01	H5649_019_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	019	0	1	01	01	H5649_019_0	9			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	019	0	1	01	01	H5649_019_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																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	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H5649	019	0	1	01	01	H5649_019_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	75.00	150.00	150.00																			75.00	150.00	150.00																75.00				75.00		2.42			2.42			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	019	0	1	01	01	H5649_019_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				74.69	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
H5649	019	0	1	01	01	H5649_019_0	9			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	022	0	1	01	01	H5649_022_0	7			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	022	0	1	01	01	H5649_022_0	7			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	022	0	1	01	01	H5649_022_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																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	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H5649	022	0	1	01	01	H5649_022_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	75.00	150.00	150.00																			75.00	150.00	150.00																75.00				75.00		2.42			2.42			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	022	0	1	01	01	H5649_022_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				157.94	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
H5649	022	0	1	01	01	H5649_022_0	7			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	023	0	1	01	01	H5649_023_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	023	0	1	01	01	H5649_023_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	023	0	1	01	01	H5649_023_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																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	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H5649	023	0	1	01	01	H5649_023_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	75.00	150.00	150.00																			75.00	150.00	150.00																75.00				75.00		2.42			2.42			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	023	0	1	01	01	H5649_023_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				176.36	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
H5649	023	0	1	01	01	H5649_023_0	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	025	1	1	01	01	H5649_025_1	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	025	1	1	01	01	H5649_025_1	8			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	9.00	18.00	18.00																			9.00	18.00	18.00																9.00				9.00		0.29			0.29			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	025	1	1	01	01	H5649_025_1	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	94.00																			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5649	025	1	1	01	01	H5649_025_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	90.00	180.00	180.00																			90.00	180.00	180.00																90.00				90.00		2.90			2.90			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	025	1	1	01	01	H5649_025_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				131.67	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
H5649	025	1	1	01	01	H5649_025_1	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	025	2	1	01	01	H5649_025_2	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	025	2	1	01	01	H5649_025_2	8			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	9.00	18.00	18.00																			9.00	18.00	18.00																9.00				9.00		0.29			0.29			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	025	2	1	01	01	H5649_025_2	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	94.00																			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5649	025	2	1	01	01	H5649_025_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	90.00	180.00	180.00																			90.00	180.00	180.00																90.00				90.00		2.90			2.90			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	025	2	1	01	01	H5649_025_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				131.67	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
H5649	025	2	1	01	01	H5649_025_2	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	027	0	1	01	01	H5649_027_0	7			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	027	0	1	01	01	H5649_027_0	7			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	027	0	1	01	01	H5649_027_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	94.00																			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	70.00				35.00	70.00	70.00				35.00		35.00
H5649	027	0	1	01	01	H5649_027_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	027	0	1	01	01	H5649_027_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				260.94	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
H5649	027	0	1	01	01	H5649_027_0	7			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	028	0	1	01	01	H5649_028_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	028	0	1	01	01	H5649_028_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	028	0	1	01	01	H5649_028_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																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	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H5649	028	0	1	01	01	H5649_028_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	028	0	1	01	01	H5649_028_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				269.46	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
H5649	028	0	1	01	01	H5649_028_0	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	029	0	1	01	01	H5649_029_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	029	0	1	01	01	H5649_029_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs																								
H5649	029	0	1	01	01	H5649_029_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	35.00	70.00	70.00																			35.00	70.00	70.00																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	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H5649	029	0	1	01	01	H5649_029_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	75.00	150.00	150.00																			75.00	150.00	150.00																75.00				75.00		2.42			2.42			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5649	029	0	1	01	01	H5649_029_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				143.28	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
H5649	029	0	1	01	01	H5649_029_0	8			Select Care Drugs	4	11	3	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
H5652	001	0	1	02	01	H5652_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																								
H5652	001	0	1	02	01	H5652_001_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																								
H5652	001	0	1	02	01	H5652_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
H5652	001	0	1	02	01	H5652_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5652	001	0	1	02	01	H5652_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				261.00	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
H5652	003	0	1	02	01	H5652_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																								
H5652	003	0	1	02	01	H5652_003_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																								
H5652	003	0	1	02	01	H5652_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										28.00		84.00						84.00			74.00	28.00		28.00
H5652	003	0	1	02	01	H5652_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5652	003	0	1	02	01	H5652_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				132.00	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
H5652	004	0	1	02	01	H5652_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																								
H5652	004	0	1	02	01	H5652_004_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																								
H5652	004	0	1	02	01	H5652_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										25.00		75.00						75.00			65.00	25.00		25.00
H5652	004	0	1	02	01	H5652_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5652	004	0	1	02	01	H5652_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				242.00	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
H5652	006	0	1	02	01	H5652_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																								
H5652	006	0	1	02	01	H5652_006_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																								
H5652	006	0	1	02	01	H5652_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
H5652	006	0	1	02	01	H5652_006_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5652	006	0	1	02	01	H5652_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				200.00	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
H5652	008	0	1	02	01	H5652_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																								
H5652	008	0	1	02	01	H5652_008_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																								
H5652	008	0	1	02	01	H5652_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
H5652	008	0	1	02	01	H5652_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H5652	008	0	1	02	01	H5652_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				193.00	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
H5718	001	0	1	04	01	H5718_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5718	001	0	1	04	01	H5718_001_0	7			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
H5718	001	0	1	04	01	H5718_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H5718	001	0	1	04	01	H5718_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				46.00	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
H5718	001	0	1	04	01	H5718_001_0	7			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
H5718	002	0	1	04	01	H5718_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5718	002	0	1	04	01	H5718_002_0	7			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
H5718	002	0	1	04	01	H5718_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				58.00	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
H5718	002	0	1	04	01	H5718_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				46.00	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
H5718	002	0	1	04	01	H5718_002_0	7			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
H5718	003	0	1	04	01	H5718_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5718	003	0	1	04	01	H5718_003_0	7			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
H5718	003	0	1	04	01	H5718_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H5718	003	0	1	04	01	H5718_003_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				46.00	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
H5718	003	0	1	04	01	H5718_003_0	7			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
H5774	005	0	1	01	01	H5774_005_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	005	0	1	01	01	H5774_005_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	005	0	1	01	01	H5774_005_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					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	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					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										35.00		70.00	5.00		10.00			10.00				35.00		5.00
H5774	005	0	1	01	01	H5774_005_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	005	0	1	01	01	H5774_005_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	022	0	1	01	01	H5774_022_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	022	0	1	01	01	H5774_022_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	022	0	1	01	01	H5774_022_0	6			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	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					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										35.00		70.00	5.00		10.00			10.00				35.00		5.00
H5774	022	0	1	01	01	H5774_022_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	022	0	1	01	01	H5774_022_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	027	0	1	02	01	H5774_027_0	7			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	7			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	7			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	7			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										35.00		70.00	25.00		50.00			50.00				35.00		25.00
H5774	027	0	1	02	01	H5774_027_0	7			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	7			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	7			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	7			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		20.00					0.00		0.00							0.00																10.00				0.00			0.33	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	7			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								45.00		90.00					25.00		50.00							50.00																45.00				25.00			1.50	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	7			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								60.00		120.00					40.00		80.00							80.00																60.00				40.00			2.00	1.33				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00		70.00	35.00		70.00			70.00				35.00		35.00
H5774	031	0	1	02	01	H5774_031_0	7			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	7			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	7			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	7			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	7			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	7			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										35.00		70.00	15.00		30.00			30.00				35.00		15.00
H5774	038	0	1	01	01	H5774_038_0	7			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	7			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
H5779	002	0	1	01	01	H5779_002_0	5			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																								
H5779	002	0	1	01	01	H5779_002_0	5			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																								
H5779	002	0	1	01	01	H5779_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											149.64	25	25	25				149.64	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
H5779	002	0	1	01	01	H5779_002_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											53.23	43	43	43				51.99	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
H5779	002	0	1	01	01	H5779_002_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, Select Care Drugs																								
H5779	002	0	1	01	01	H5779_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	0.00				0.00				0.00			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	5			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																								
H5779	007	0	1	01	01	H5779_007_0	5			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																								
H5779	007	0	1	01	01	H5779_007_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											147.70	25	25	25				147.70	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
H5779	007	0	1	01	01	H5779_007_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											54.32	44	44	44				54.32	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
H5779	007	0	1	01	01	H5779_007_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, Select Care Drugs																								
H5779	007	0	1	01	01	H5779_007_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																								
H5779	009	0	1	01	01	H5779_009_0	5			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																								
H5779	009	0	1	01	01	H5779_009_0	5			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																								
H5779	009	0	1	01	01	H5779_009_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											146.39	25	25	25				146.39	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
H5779	009	0	1	01	01	H5779_009_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											53.57	37	37	37				52.12	36	36	36										37	37	37				36	36	36			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
H5779	009	0	1	01	01	H5779_009_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, Select Care Drugs																								
H5779	009	0	1	01	01	H5779_009_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																								
H5793	001	0	1	02	01	H5793_001_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	001	0	1	02	01	H5793_001_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	001	0	1	02	01	H5793_001_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.94	24	24	24				110.46	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
H5793	001	0	1	02	01	H5793_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.80	25	25	25				40.31	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	105.00	35.00	70.00	105.00	35.00		35.00
H5793	001	0	1	02	01	H5793_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											744.48	25						868.04	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
H5793	010	0	1	02	01	H5793_010_0	5			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	010	0	1	02	01	H5793_010_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	010	0	1	02	01	H5793_010_0	5			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.48	22	22	22				100.90	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.23	25	25	25				47.33	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
H5793	010	0	1	02	01	H5793_010_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											910.21	27						756.26	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
H5793	014	0	1	02	01	H5793_014_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	014	0	1	02	01	H5793_014_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	014	0	1	02	01	H5793_014_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.30	24	24	24				103.79	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
H5793	014	0	1	02	01	H5793_014_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											37.96	25	25	25				36.85	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
H5793	014	0	1	02	01	H5793_014_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											806.67	25						880.72	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
H5793	015	0	1	02	01	H5793_015_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	015	0	1	02	01	H5793_015_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5793	015	0	1	02	01	H5793_015_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.07	25	25	25				103.95	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
H5793	015	0	1	02	01	H5793_015_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											44.35	26	26	26				37.28	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	02	01	H5793_015_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											906.27	30						920.89	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
H5793	018	0	1	02	01	H5793_018_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	018	0	1	02	01	H5793_018_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	018	0	1	02	01	H5793_018_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.62	22	22	22				91.51	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.12	25	25	25				38.75	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
H5793	018	0	1	02	01	H5793_018_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											826.84	27						861.71	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
H5793	019	0	1	02	01	H5793_019_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H5793	019	0	1	02	01	H5793_019_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5793	019	0	1	02	01	H5793_019_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.85	25	25	25				96.92	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
H5793	019	0	1	02	01	H5793_019_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.77	35	35	35				34.12	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
H5793	019	0	1	02	01	H5793_019_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1274.28	33						1316.44	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
H5810	014	0	1	01	01	H5810_014_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				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	10			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				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	10			Preferred Brand	4	11	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	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	10			Non-Preferred Drug	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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5810	014	0	1	01	01	H5810_014_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				369.96	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	10			Select Care Drugs	4	11	1	2	6	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 Drug, Specialty Tier, Select Care Drugs																								
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											62.29	50	50	50				61.81	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
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	01	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	01	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	10	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											47.14	50	50	50				43.07	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
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																								
H5828	013	0	1	02	01	H5828_013_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																								
H5828	013	0	1	02	01	H5828_013_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																								
H5828	013	0	1	02	01	H5828_013_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											42.21	20	20	20				42.21	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	70.00				35.00		35.00
H5828	013	0	1	02	01	H5828_013_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											31.98	35	35	35				31.98	35	35	35				35	35	35															35			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
H5828	013	0	1	02	01	H5828_013_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																								
H5828	013	0	1	02	01	H5828_013_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																								
H5828	014	0	1	02	01	H5828_014_0	8			Preferred Generic	4	11	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																								
H5828	014	0	1	02	01	H5828_014_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																								
H5828	014	0	1	02	01	H5828_014_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											82.88	20	20	20				82.88	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	70.00				35.00		35.00
H5828	014	0	1	02	01	H5828_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											18.61	35	35	35				18.61	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		35.00
H5828	014	0	1	02	01	H5828_014_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																								
H5828	015	0	1	02	01	H5828_015_0	8			Preferred Generic	4	11	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																								
H5828	015	0	1	02	01	H5828_015_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																								
H5828	015	0	1	02	01	H5828_015_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											86.26	20	20	20				86.26	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	70.00				35.00		35.00
H5828	015	0	1	02	01	H5828_015_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											19.39	35	35	35				19.39	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		35.00
H5828	015	0	1	02	01	H5828_015_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																								
H5828	016	0	1	02	01	H5828_016_0	8			Preferred Generic	4	11	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																								
H5828	016	0	1	02	01	H5828_016_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																								
H5828	016	0	1	02	01	H5828_016_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											76.84	20	20	20				76.84	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	70.00				35.00		35.00
H5828	016	0	1	02	01	H5828_016_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											17.29	35	35	35				17.29	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		35.00
H5828	016	0	1	02	01	H5828_016_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																								
H5828	017	0	1	02	01	H5828_017_0	8			Preferred Generic	4	11	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																								
H5828	017	0	1	02	01	H5828_017_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																								
H5828	017	0	1	02	01	H5828_017_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.15	20	20	20				84.15	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	70.00				35.00		35.00
H5828	017	0	1	02	01	H5828_017_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											18.89	35	35	35				18.89	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		35.00
H5828	017	0	1	02	01	H5828_017_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																								
H5843	001	0	1	01	01	H5843_001_0	6			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	6			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	6			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					94.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H5843	001	0	1	01	01	H5843_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					200.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H5843	001	0	1	01	01	H5843_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				602.04	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5843	002	0	1	01	01	H5843_002_0	6			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	6			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	6			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					94.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H5843	002	0	1	01	01	H5843_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					200.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H5843	002	0	1	01	01	H5843_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				758.50	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5843	005	0	1	01	01	H5843_005_0	6			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	6			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	6			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					94.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H5843	005	0	1	01	01	H5843_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					200.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00						70.00				35.00		35.00
H5843	005	0	1	01	01	H5843_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				866.43	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5852	001	0	1	01	01	H5852_001_0	6			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		105.00										35.00		35.00
H5852	001	0	1	01	01	H5852_001_0	6			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		105.00										35.00		35.00
H5852	001	0	1	01	01	H5852_001_0	6			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	6			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										35.00		105.00										35.00		35.00
H5852	001	0	1	01	01	H5852_001_0	6			Select Care Drugs	4	01	1	2	5	1	110		01			1	30		100				1	2							30		34	0.00		0.00																																					0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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			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					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	009	0	1	01	01	H5854_009_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.89	20	20	20				72.89	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		35.00
H5854	009	0	1	01	01	H5854_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											68.17	35	35	35				68.17	35	35	35				35	35	35															35			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
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												28							28						28																	28			28								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	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																								
H5854	010	0	1	02	01	H5854_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																								
H5854	010	0	1	02	01	H5854_010_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H5854	010	0	1	02	01	H5854_010_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.82	20	20	20				72.82	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	70.00				35.00		35.00
H5854	010	0	1	02	01	H5854_010_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											69.15	35	35	35				69.15	35	35	35				35	35	35															35			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
H5854	010	0	1	02	01	H5854_010_0	7			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	02	01	H5854_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																								
H5854	012	0	1	02	01	H5854_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5854	012	0	1	02	01	H5854_012_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H5854	012	0	1	02	01	H5854_012_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											69.19	25	25	25				55.35	20	20	20				20	20	20															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		35.00
H5854	012	0	1	02	01	H5854_012_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											85.02	25	25	25				85.02	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		35.00
H5854	012	0	1	02	01	H5854_012_0	7			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	012	0	1	02	01	H5854_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																								
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				1	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	Preferred Brand	4	10	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								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				1	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	Specialty Tier	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								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	1.60																																							1.60				1.60		0.05						0.05	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																								
H5883	002	1	1	02	01	H5883_002_1	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				47.00	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	002	1	1	02	01	H5883_002_1	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				47.00	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	002	2	1	02	01	H5883_002_2	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				47.00	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	002	3	1	02	01	H5883_002_3	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				47.00	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	002	4	1	02	01	H5883_002_4	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				47.00	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	002	7	1	02	01	H5883_002_7	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											53.00	50		50				49.00	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	003	1	1	02	01	H5883_003_1	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											53.00	50		50				49.00	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	003	2	1	02	01	H5883_003_2	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											53.00	50		50				49.00	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	003	3	1	02	01	H5883_003_3	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											53.00	50		50				49.00	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	003	4	1	02	01	H5883_003_4	7			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	7			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	7			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	7			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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											53.00	50		50				49.00	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	003	5	1	02	01	H5883_003_5	7			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	9			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	9			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	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		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	9			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											59.00	50		50				48.00	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	007	0	1	01	01	H5883_007_0	9			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	8			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	8			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	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					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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	50		50				52.00	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	8			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	8			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	8			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	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					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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	50		50				52.00	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	8			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	10			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	10			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	10			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	10			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											52.00	50		50				50.00	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	10			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	10			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	10			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	10			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	10			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											52.00	50		50				50.00	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	10			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	10			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	10			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	10			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	10			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											52.00	50		50				50.00	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	10			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	10			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	10			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	10			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	10			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											52.00	50		50				50.00	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	10			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	10			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	10			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	10			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	10			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											52.00	50		50				50.00	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	10			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	7			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	7			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	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					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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											54.00	50		50				54.00	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	7			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	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																								
H5900	001	0	1	04	01	H5900_001_0	11			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	24.00	0.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5900	001	0	1	04	01	H5900_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
H5900	001	0	1	04	01	H5900_001_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				100.00	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
H5900	001	0	1	04	01	H5900_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1600.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5900	002	0	1	04	01	H5900_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																								
H5900	002	0	1	04	01	H5900_002_0	11			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	0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5900	002	0	1	04	01	H5900_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
H5900	002	0	1	04	01	H5900_002_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				100.00	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
H5900	002	0	1	04	01	H5900_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1600.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5900	003	0	1	04	01	H5900_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																								
H5900	003	0	1	04	01	H5900_003_0	11			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	24.00	0.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5900	003	0	1	04	01	H5900_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
H5900	003	0	1	04	01	H5900_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				100.00	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
H5900	003	0	1	04	01	H5900_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1600.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5900	004	0	1	04	01	H5900_004_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																								
H5900	004	0	1	04	01	H5900_004_0	11			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	24.00	0.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5900	004	0	1	04	01	H5900_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
H5900	004	0	1	04	01	H5900_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				100.00	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
H5900	004	0	1	04	01	H5900_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1600.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	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																								
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	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
H5900	005	0	1	04	01	H5900_005_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				100.00	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
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																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H5926	001	0	1	01	01	H5926_001_0	10		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				2	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 Drug, Specialty Tier, Select Care Drugs																								
H5926	001	0	1	01	01	H5926_001_0	10		N	Generic	4	01	1	1	2	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31				3.28	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5926	001	0	1	01	01	H5926_001_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31				46.66	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	94.00				35.00		35.00
H5926	001	0	1	01	01	H5926_001_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31				64.78	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	94.00				35.00		35.00
H5926	001	0	1	01	01	H5926_001_0	10		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				687.79	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
H5926	001	0	1	01	01	H5926_001_0	10		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	100				2	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 Drug, Specialty Tier, Select Care Drugs																								
H5926	005	0	1	01	01	H5926_005_0	10		N	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	005	0	1	01	01	H5926_005_0	10		N	Generic	4	01	1	1	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31				9.09	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5926	005	0	1	01	01	H5926_005_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31				61.19	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	94.00				35.00		35.00
H5926	005	0	1	01	01	H5926_005_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31				80.31	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	94.00				35.00		35.00
H5926	005	0	1	01	01	H5926_005_0	10		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				686.58	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
H5926	005	0	1	01	01	H5926_005_0	10		N	Select Care Drugs	4	11	1	2	6	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																								
H5928	004	0	1	01	01	H5928_004_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																								
H5928	004	0	1	01	01	H5928_004_0	5			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	5			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	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	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																								
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			Generic	4	01	1	2	2	1		111	01	100		1				30	60	100	2	2			100				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			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	2	2			100				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	100	2	2			100				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																								
H5938	001	0	1	01	01	H5938_001_0	16			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	16			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	16			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	16			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	16			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																								
H5938	001	0	1	01	01	H5938_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	0.00	0.00	0.00																			0.00	0.00	0.00																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	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			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			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					30																																					30			30								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	008	0	1	01	01	H5938_008_0	10			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	10			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	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					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	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					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	10			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	10			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																								
H5943	001	0	1	02	01	H5943_001_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																								
H5943	001	0	1	02	01	H5943_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	21.00					2.00	4.00	6.00											7.00	14.00	21.00				2.00	4.00	6.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5943	001	0	1	02	01	H5943_001_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											105.40	25	25	25				105.40	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
H5943	001	0	1	02	01	H5943_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											60.99	25	25	25				60.99	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
H5943	001	0	1	02	01	H5943_001_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																								
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																								
H5943	002	0	1	02	01	H5943_002_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					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																								
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											105.54	25	25	25				105.54	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
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											66.30	25	25	25				66.30	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
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																								
H5945	001	0	1	01	01	H5945_001_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	001	0	1	01	01	H5945_001_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	001	0	1	01	01	H5945_001_0	5			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00						105.00				35.00		35.00
H5945	001	0	1	01	01	H5945_001_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	001	0	1	01	01	H5945_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				95.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	001	0	1	01	01	H5945_001_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	002	0	1	01	01	H5945_002_0	4			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	4			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	4			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	45.00	90.00	90.00																					90.00																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	70.00						70.00				35.00		35.00
H5945	002	0	1	01	01	H5945_002_0	4			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	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				122.22	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	002	0	1	01	01	H5945_002_0	4			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	013	0	1	01	01	H5945_013_0	3			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	013	0	1	01	01	H5945_013_0	3			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	013	0	1	01	01	H5945_013_0	3			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				125.12	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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				54.57	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	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				166.36	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	013	0	1	01	01	H5945_013_0	3			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	014	0	1	01	01	H5945_014_0	3			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	014	0	1	01	01	H5945_014_0	3			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	014	0	1	01	01	H5945_014_0	3			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				125.58	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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				56.06	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	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				169.73	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	014	0	1	01	01	H5945_014_0	3			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	3			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	3			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	3			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	45.00	90.00	90.00																					90.00																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	70.00						70.00				35.00		35.00
H5945	016	0	1	01	01	H5945_016_0	3			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	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				111.01	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	016	0	1	01	01	H5945_016_0	3			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	017	0	1	01	01	H5945_017_0	3		N	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	017	0	1	01	01	H5945_017_0	3		N	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	017	0	1	01	01	H5945_017_0	3		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				130.66	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	3		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				98.70	47	47	47																				47															47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5945	017	0	1	01	01	H5945_017_0	3		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				199.44	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	017	0	1	01	01	H5945_017_0	3		N	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	018	0	1	01	01	H5945_018_0	3		N	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	018	0	1	01	01	H5945_018_0	3		N	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	018	0	1	01	01	H5945_018_0	3		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				133.02	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	3		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				98.60	43	43	43																				43															43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5945	018	0	1	01	01	H5945_018_0	3		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				215.68	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	018	0	1	01	01	H5945_018_0	3		N	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	3			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	3			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	3			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				126.74	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						105.00				35.00		35.00
H5945	027	0	1	01	01	H5945_027_0	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				35.92	40	40	40																				40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H5945	027	0	1	01	01	H5945_027_0	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				146.58	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H5945	027	0	1	01	01	H5945_027_0	3			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																								
H5959	009	0	1	04	01	H5959_009_0	5			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	5			Generic	4	01	1	2	2	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	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				83.99	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	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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				72.59	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	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	010	1	1	04	01	H5959_010_1	6			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	6			Generic	4	01	1	2	2	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	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	94.00																									47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00		1.51				1.51	1.51	1.51	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	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				78.76	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	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	010	2	1	04	01	H5959_010_2	6			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	6			Generic	4	01	1	2	2	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	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	94.00																									47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00		1.51				1.51	1.51	1.51	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	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				78.76	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	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	011	0	1	04	01	H5959_011_0	5			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	5			Generic	4	01	1	2	2	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	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	94.00																									47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00		1.51				1.51	1.51	1.51	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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				73.60	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	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	012	0	1	04	01	H5959_012_0	3			Preferred Generic	4	01	3	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	3			Generic	4	01	1	2	2	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	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				70.89	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	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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				62.81	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	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	013	1	1	04	01	H5959_013_1	3			Preferred Generic	4	01	3	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	3			Generic	4	01	1	2	2	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	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				75.46	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	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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				59.79	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	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	013	2	1	04	01	H5959_013_2	3			Preferred Generic	4	01	3	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	3			Generic	4	01	1	2	2	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	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				75.46	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	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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				59.79	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	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	014	1	1	04	01	H5959_014_1	6			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	6			Generic	4	01	1	2	2	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	6			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				82.32	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	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	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				71.99	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	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	014	2	1	04	01	H5959_014_2	6			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	6			Generic	4	01	1	2	2	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	6			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				82.32	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	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	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				71.99	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	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	015	0	1	04	01	H5959_015_0	4			Preferred Generic	4	01	3	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	4			Generic	4	01	1	2	2	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	4			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				71.30	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	015	0	1	04	01	H5959_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				54.74	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	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5959	016	0	1	04	01	H5959_016_0	4			Preferred Generic	4	01	3	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	4			Generic	4	01	1	2	2	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	4			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				65.89	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
H5959	016	0	1	04	01	H5959_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				57.42	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	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H5965	002	0	1	04	01	H5965_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																								
H5965	002	0	1	04	01	H5965_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H5965	002	0	1	04	01	H5965_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.31	25	25	25				154.31	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
H5965	002	0	1	04	01	H5965_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											60.02	50	50	50				60.02	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
H5965	002	0	1	04	01	H5965_002_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, Select Care Drugs																								
H5965	002	0	1	04	01	H5965_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																								
H5965	007	0	1	04	01	H5965_007_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																								
H5965	007	0	1	04	01	H5965_007_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H5965	007	0	1	04	01	H5965_007_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											148.84	25	25	25				148.84	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
H5965	007	0	1	04	01	H5965_007_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											53.18	50	50	50				53.18	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
H5965	007	0	1	04	01	H5965_007_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, Select Care Drugs																								
H5965	007	0	1	04	01	H5965_007_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																								
H5970	028	0	1	04	01	H5970_028_0	3			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	028	0	1	04	01	H5970_028_0	3			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
H5970	028	0	1	04	01	H5970_028_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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H5970	028	0	1	04	01	H5970_028_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		105.00	35.00		35.00
H5970	028	0	1	04	01	H5970_028_0	3			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
H5970	029	0	1	04	01	H5970_029_0	4			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
H5970	029	0	1	04	01	H5970_029_0	4			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
H5970	029	0	1	04	01	H5970_029_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		95.00	35.00		35.00
H5970	029	0	1	04	01	H5970_029_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		35.00
H5970	029	0	1	04	01	H5970_029_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
H5989	011	0	1	01	01	H5989_011_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										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	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	15.00																			15.00	30.00	15.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	30.00	15.00				15.00	30.00	15.00				15.00		15.00
H5989	011	0	1	01	01	H5989_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	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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.77	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
H5989	011	0	1	01	01	H5989_011_0	7			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
H5992	007	0	1	01	01	H5992_007_0	10		N	Preferred Generic	4	01	1	1	1	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 Drug, Specialty Tier																								
H5992	007	0	1	01	01	H5992_007_0	10		N	Generic	4	01	1	1	2	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 Drug, Specialty Tier																								
H5992	007	0	1	01	01	H5992_007_0	10		N	Preferred Brand	4	10	1	1	3	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 Drug, Specialty Tier										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5992	007	0	1	01	01	H5992_007_0	10		N	Non-Preferred Drug	4	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 Drug, Specialty Tier										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5992	007	0	1	01	01	H5992_007_0	10		N	Specialty Tier	4	11	1	1	5	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 Drug, Specialty Tier										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5995	004	0	1	01	01	H5995_004_0	11			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																								
H5995	004	0	1	01	01	H5995_004_0	11			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										20.00		40.00						40.00				20.00		20.00
H5995	004	0	1	01	01	H5995_004_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
H5995	004	0	1	01	01	H5995_004_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										35.00		70.00						70.00				35.00		35.00
H5995	004	0	1	01	01	H5995_004_0	11			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																								
H5995	004	0	1	01	01	H5995_004_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																								
H6018	001	0	1	04	01	H6018_001_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										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	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																			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
H6018	001	0	1	04	01	H6018_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.00	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
H6018	001	0	1	04	01	H6018_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				39.00	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
H6018	001	0	1	04	01	H6018_001_0	7			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
H6018	002	0	1	04	01	H6018_002_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
H6018	002	0	1	04	01	H6018_002_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																			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
H6018	002	0	1	04	01	H6018_002_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				69.00	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
H6018	002	0	1	04	01	H6018_002_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				46.00	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
H6018	002	0	1	04	01	H6018_002_0	8			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
H6018	003	0	1	04	01	H6018_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										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	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																			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
H6018	003	0	1	04	01	H6018_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				74.00	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
H6018	003	0	1	04	01	H6018_003_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				39.00	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
H6018	003	0	1	04	01	H6018_003_0	7			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
H6018	007	0	1	04	01	H6018_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	Preferred Generic, 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	007	0	1	04	01	H6018_007_0	7			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
H6018	007	0	1	04	01	H6018_007_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	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
H6018	007	0	1	04	01	H6018_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				47.00	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
H6018	007	0	1	04	01	H6018_007_0	7			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
H6018	008	0	1	04	01	H6018_008_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6018	008	0	1	04	01	H6018_008_0	7			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	008	0	1	04	01	H6018_008_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				60.00	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
H6018	008	0	1	04	01	H6018_008_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				47.00	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
H6018	008	0	1	04	01	H6018_008_0	7			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
H6018	010	0	1	04	01	H6018_010_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6018	010	0	1	04	01	H6018_010_0	7			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	010	0	1	04	01	H6018_010_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	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
H6018	010	0	1	04	01	H6018_010_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				47.00	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
H6018	010	0	1	04	01	H6018_010_0	7			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
H6018	011	0	1	04	01	H6018_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6018	011	0	1	04	01	H6018_011_0	7			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	011	0	1	04	01	H6018_011_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				60.00	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
H6018	011	0	1	04	01	H6018_011_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				47.00	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
H6018	011	0	1	04	01	H6018_011_0	7			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				2	2	30	60	90				30		31				5.80	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				2	2	30	60	90				30		31				127.51	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
H6080	001	0	1	48	05	H6080_001_0	2			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	2			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	2			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	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																								
H6154	001	0	1	02	01	H6154_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					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																								
H6154	001	0	1	02	01	H6154_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.22	16	16	16				54.30	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
H6154	001	0	1	02	01	H6154_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											110.11	50	50	50				75.89	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
H6154	001	0	1	02	01	H6154_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																								
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																								
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	5.00		12.50																			5.00		0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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		141.00																			47.00		131.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00				35.00		35.00
H6158	001	0	1	01	01	H6158_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				90.06	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
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				68.64	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H6158	003	0	1	01	01	H6158_003_0	4			Preferred Generic	3	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		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																								
H6158	003	0	1	01	01	H6158_003_0	4			Generic	3	11	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	18.00		54.00																			18.00		54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6158	003	0	1	01	01	H6158_003_0	4			Preferred Brand	3	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				42.43	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
H6158	003	0	1	01	01	H6158_003_0	4			Non-Preferred Drug	3	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				89.66	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
H6158	003	0	1	01	01	H6158_003_0	4			Specialty Tier	3	11	1	1	5	1	010		01	010		1	30								30						30		31				153.83	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H6170	001	0	1	02	01	H6170_001_0	14			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	02	01	H6170_001_0	14			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	3.00		9.00																					6.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										3.00		9.00						6.00				3.00		3.00
H6170	001	0	1	02	01	H6170_001_0	14			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	02	01	H6170_001_0	14			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	02	01	H6170_001_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				727.01	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	02	01	H6170_001_0	14			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	02	01	H6170_002_0	13			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	02	01	H6170_002_0	13			Generic	4	01	1	2	2	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	02	01	H6170_002_0	13			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				104.00	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	02	01	H6170_002_0	13			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				73.73	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	02	01	H6170_002_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				405.19	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	02	01	H6170_002_0	13			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	02	01	H6170_003_0	13			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	02	01	H6170_003_0	13			Generic	4	01	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31				11.76	25		25																				25															25			25								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	02	01	H6170_003_0	13			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				112.92	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
H6170	003	0	1	02	01	H6170_003_0	13			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				69.61	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	02	01	H6170_003_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				395.51	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	02	01	H6170_003_0	13			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
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 Drug, 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	001	0	1	04	01	H6200_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					100.00	200.00	300.00							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			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												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
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 Drug, 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	002	0	1	04	01	H6200_002_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					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 Drug, 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 Drug, 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 Drug, 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	003	0	1	04	01	H6200_003_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											98.44	46	46	46				46.99	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			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												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
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 Drug, 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	004	0	1	04	01	H6200_004_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											98.74	46	46	46				46.92	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			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												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
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 Drug, 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	005	0	1	04	01	H6200_005_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											93.73	46	46	46				78.37	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			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												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
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 Drug, 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			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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	006	0	1	04	01	H6200_006_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											93.37	46	46	46				77.95	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			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												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
H6200	007	0	1	04	01	H6200_007_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 Drug, 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	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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
H6200	007	0	1	04	01	H6200_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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	007	0	1	04	01	H6200_007_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											78.19	46	46	46				67.64	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			105.00				35.00		35.00
H6200	007	0	1	04	01	H6200_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
H6200	008	0	1	04	01	H6200_008_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								15.00	30.00	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										15.00	30.00	45.00	0.00	0.00	0.00			0.00				15.00		15.00
H6200	008	0	1	04	01	H6200_008_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								20.00	40.00	60.00					3.00	6.00	9.00							7.50																20.00				20.00			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			7.50				20.00		20.00
H6200	008	0	1	04	01	H6200_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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	008	0	1	04	01	H6200_008_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											81.91	46	46	46				40.55	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			105.00				35.00		35.00
H6200	008	0	1	04	01	H6200_008_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
H6200	009	0	1	04	01	H6200_009_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 Drug, Specialty Tier										4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	009	0	1	04	01	H6200_009_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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
H6200	009	0	1	04	01	H6200_009_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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	009	0	1	04	01	H6200_009_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					100.00	200.00	300.00							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			105.00				35.00		35.00
H6200	009	0	1	04	01	H6200_009_0	4			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
H6200	010	0	1	04	01	H6200_010_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 Drug, Specialty Tier										4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	010	0	1	04	01	H6200_010_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					3.00	6.00	9.00							7.50																12.00				12.00			0.40	0.10				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00			7.50				12.00		12.00
H6200	010	0	1	04	01	H6200_010_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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	010	0	1	04	01	H6200_010_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					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 Drug, Specialty Tier										35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	010	0	1	04	01	H6200_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										35.00			35.00			35.00						35.00		35.00
H6200	011	0	1	04	01	H6200_011_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								15.00	30.00	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										15.00	30.00	45.00	0.00	0.00	0.00			0.00				15.00		15.00
H6200	011	0	1	04	01	H6200_011_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								20.00	40.00	60.00					3.00	6.00	9.00							7.50																20.00				20.00			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			7.50				20.00		20.00
H6200	011	0	1	04	01	H6200_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					47.00	94.00	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	105.00			105.00				35.00		35.00
H6200	011	0	1	04	01	H6200_011_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	1	2			90				30		31											75.60	46	46	46				63.89	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			105.00				35.00		35.00
H6200	011	0	1	04	01	H6200_011_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
H6202	001	0	1	04	01	H6202_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	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	10			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	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, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6202	001	0	1	04	01	H6202_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	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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6202	001	0	1	04	01	H6202_001_0	10			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																								
H6202	001	0	1	04	01	H6202_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H6202	002	0	1	04	01	H6202_002_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																								
H6202	002	0	1	04	01	H6202_002_0	9			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	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	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	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6202	002	0	1	04	01	H6202_002_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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6202	002	0	1	04	01	H6202_002_0	9			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	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																								
H6237	009	0	1	01	01	H6237_009_0	5			Preferred Generic	4	01	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										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
H6237	009	0	1	01	01	H6237_009_0	5			Generic	4	01	1	2	2	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										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
H6237	009	0	1	01	01	H6237_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								25.00	50.00	75.00					18.00	36.00	54.00											25.00	50.00	75.00				18.00	36.00	54.00				25.00				25.00			0.83	0.60		0.83	0.60	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										25.00	50.00	75.00	18.00	36.00	54.00	25.00	50.00	75.00	18.00	36.00	54.00	25.00		25.00
H6237	009	0	1	01	01	H6237_009_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											37.07	27	27	27				37.07	23	23	23										27	27	27				23	23	23			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
H6237	009	0	1	01	01	H6237_009_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											773.66	33						773.66	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6248	001	0	1	01	01	H6248_001_0	5			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										0.00	0.00	0.00						0.00				0.00		0.00
H6248	001	0	1	01	01	H6248_001_0	5			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	5			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	5			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										35.00	70.00	105.00						105.00				35.00		35.00
H6248	001	0	1	01	01	H6248_001_0	5			Specialty Tier	4	11	1	1	5	1	111		01	010		1	31	62	93				2	2	31						31		31				2054.00	33	33	33																		33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00	70.00	105.00				35.00						35.00		35.00
H6248	001	0	1	01	01	H6248_001_0	5			Select Care Drugs	4	11	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										0.00	0.00	0.00						0.00				0.00		0.00
H6306	005	0	1	01	01	H6306_005_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																								
H6306	005	0	1	01	01	H6306_005_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	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	7			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				130.65	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
H6306	005	0	1	01	01	H6306_005_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				67.26	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	005	0	1	01	01	H6306_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																								
H6306	013	0	1	02	01	H6306_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																			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																								
H6306	013	0	1	02	01	H6306_013_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			8.00	20.00	0.00																0.00				0.00		0.00			0.27			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				8.00	20.00	0.00				0.00		0.00
H6306	013	0	1	02	01	H6306_013_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				133.99	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
H6306	013	0	1	02	01	H6306_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				90.83	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	013	0	1	02	01	H6306_013_0	5			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	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																			5.00	10.00	0.00																0.00				0.00		0.00			0.17			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6306	014	0	1	02	01	H6306_014_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			10.00	20.00	0.00																0.00				0.00		0.00			0.33			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				10.00	20.00	0.00				0.00		0.00
H6306	014	0	1	02	01	H6306_014_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				130.34	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
H6306	014	0	1	02	01	H6306_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				59.13	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	014	0	1	02	01	H6306_014_0	5			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	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	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	5			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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				133.54	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
H6306	017	0	1	02	01	H6306_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				63.46	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
H6306	017	0	1	02	01	H6306_017_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																								
H6306	018	0	1	02	01	H6306_018_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	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6306	018	0	1	02	01	H6306_018_0	5			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	018	0	1	02	01	H6306_018_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				137.08	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
H6306	018	0	1	02	01	H6306_018_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				67.91	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
H6306	018	0	1	02	01	H6306_018_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																								
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			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				486.00	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	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			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				486.00	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	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			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				486.00	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	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			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				486.00	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
H6348	002	0	1	04	01	H6348_002_0	5			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	5			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																								
H6348	002	0	1	04	01	H6348_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.69	25	25	25				157.69	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
H6348	002	0	1	04	01	H6348_002_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											59.35	40	40	40				59.35	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
H6348	002	0	1	04	01	H6348_002_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, Select Care Drugs																								
H6348	002	0	1	04	01	H6348_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H6348	008	0	1	04	01	H6348_008_0	4			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	008	0	1	04	01	H6348_008_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	20.00	30.00				0.00	0.00	0.00				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																								
H6348	008	0	1	04	01	H6348_008_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.37	25	25	25				164.37	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
H6348	008	0	1	04	01	H6348_008_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											55.92	30	30	30				55.92	30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	008	0	1	04	01	H6348_008_0	4			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																								
H6348	008	0	1	04	01	H6348_008_0	4			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	009	0	1	04	01	H6348_009_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					7.00	14.00	21.00											19.00	38.00	57.00				7.00	14.00	0.00				19.00				19.00			0.63	0.23		0.63	0.23	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H6348	009	0	1	04	01	H6348_009_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H6348	009	0	1	04	01	H6348_009_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											140.97	23	23	23				140.97	23	23	23										23	23	23				23	23	23			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
H6348	009	0	1	04	01	H6348_009_0	5			Non-Preferred Drug	3	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	200.00				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
H6348	009	0	1	04	01	H6348_009_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																								
H6348	009	0	1	04	01	H6348_009_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																								
H6348	010	0	1	04	01	H6348_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																								
H6348	010	0	1	04	01	H6348_010_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6348	010	0	1	04	01	H6348_010_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.28	25	25	25				153.28	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
H6348	010	0	1	04	01	H6348_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											62.28	40	40	40				60.73	39	39	39										40	40	40				39	39	39			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
H6348	010	0	1	04	01	H6348_010_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, Select Care Drugs																								
H6348	010	0	1	04	01	H6348_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																								
H6351	004	0	1	01	01	H6351_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	0.00	0.00	0.00																			0.00	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	6			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	6			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	6			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	6			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	6			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	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	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	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																								
H6379	001	0	1	01	01	H6379_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								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	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
H6379	001	0	1	01	01	H6379_001_0	10			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	10			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	10			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	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	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	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	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	10			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																								
H6453	013	1	1	02	01	H6453_013_1	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																								
H6453	013	1	1	02	01	H6453_013_1	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																								
H6453	013	1	1	02	01	H6453_013_1	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
H6453	013	1	1	02	01	H6453_013_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.56	50	50	50				43.20	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
H6453	013	1	1	02	01	H6453_013_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1029.13	33						492.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	013	2	1	02	01	H6453_013_2	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				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	5			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	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					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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.56	50	50	50				43.20	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
H6453	013	2	1	02	01	H6453_013_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1029.13	33						492.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	013	3	1	02	01	H6453_013_3	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				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	5			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	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					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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.56	50	50	50				43.20	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
H6453	013	3	1	02	01	H6453_013_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1029.13	33						492.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	013	4	1	02	01	H6453_013_4	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				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	5			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	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					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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.56	50	50	50				43.20	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
H6453	013	4	1	02	01	H6453_013_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1029.13	33						492.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	013	5	1	02	01	H6453_013_5	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				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	5			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	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					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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.56	50	50	50				43.20	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
H6453	013	5	1	02	01	H6453_013_5	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1029.13	33						492.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	017	1	1	02	01	H6453_017_1	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																								
H6453	017	1	1	02	01	H6453_017_1	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																								
H6453	017	1	1	02	01	H6453_017_1	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
H6453	017	1	1	02	01	H6453_017_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											53.77	50	50	50				42.30	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
H6453	017	1	1	02	01	H6453_017_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1049.01	33						574.84	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	017	2	1	02	01	H6453_017_2	5			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	5			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	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					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	017	2	1	02	01	H6453_017_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											53.77	50	50	50				42.30	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
H6453	017	2	1	02	01	H6453_017_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1049.01	33						574.84	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	018	1	1	02	01	H6453_018_1	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																								
H6453	018	1	1	02	01	H6453_018_1	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																								
H6453	018	1	1	02	01	H6453_018_1	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
H6453	018	1	1	02	01	H6453_018_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.97	50	50	50				38.07	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
H6453	018	1	1	02	01	H6453_018_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											662.30	33						366.81	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	018	2	1	02	01	H6453_018_2	5			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	5			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	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					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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.97	50	50	50				38.07	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
H6453	018	2	1	02	01	H6453_018_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											662.30	33						366.81	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	020	1	1	02	01	H6453_020_1	5			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	020	1	1	02	01	H6453_020_1	5			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	020	1	1	02	01	H6453_020_1	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					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	020	1	1	02	01	H6453_020_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.74	50	50	50				66.53	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
H6453	020	1	1	02	01	H6453_020_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1050.66	29						466.63	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6453	020	2	1	02	01	H6453_020_2	5			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	020	2	1	02	01	H6453_020_2	5			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	020	2	1	02	01	H6453_020_2	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					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	020	2	1	02	01	H6453_020_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.74	50	50	50				66.53	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
H6453	020	2	1	02	01	H6453_020_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1050.66	29						466.63	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6474	001	0	1	02	01	H6474_001_0	14			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	02	01	H6474_001_0	14			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	3.00		9.00																					6.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										3.00		9.00						6.00				3.00		3.00
H6474	001	0	1	02	01	H6474_001_0	14			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	02	01	H6474_001_0	14			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	02	01	H6474_001_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				727.01	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	02	01	H6474_001_0	14			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	02	01	H6474_002_0	13			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	02	01	H6474_002_0	13			Generic	4	01	1	2	2	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	02	01	H6474_002_0	13			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				104.00	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	02	01	H6474_002_0	13			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				73.73	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	02	01	H6474_002_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				405.19	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	02	01	H6474_002_0	13			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	02	01	H6474_003_0	13			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	02	01	H6474_003_0	13			Generic	4	01	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31				11.76	25		25																				25															25			25								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	02	01	H6474_003_0	13			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				112.92	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	02	01	H6474_003_0	13			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				69.61	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	02	01	H6474_003_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				395.51	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	02	01	H6474_003_0	13			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
H6529	001	1	1	01	01	H6529_001_1	9			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 Brand, 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	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					0.00	0.00	0.00					8.00	16.00	0.00																	15.00			15.00			0.50	0.00	0.27			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										15.00	30.00	45.00	0.00	0.00	0.00	8.00	16.00	0.00				15.00		15.00
H6529	001	1	1	01	01	H6529_001_1	9			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					41.00	82.00	123.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.37	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
H6529	001	1	1	01	01	H6529_001_1	9			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											97.59	33	33	33				95.55	33	33	33				33	33	33																33		33								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
H6529	001	1	1	01	01	H6529_001_1	9			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 Brand, Specialty Tier, Select Care Drugs										35.00			35.00									35.00		35.00
H6529	001	1	1	01	01	H6529_001_1	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			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	0.00				0.00		0.00
H6529	001	2	1	01	01	H6529_001_2	9			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 Brand, 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	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					0.00	0.00	0.00					8.00	16.00	0.00																	15.00			15.00			0.50	0.00	0.27			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										15.00	30.00	45.00	0.00	0.00	0.00	8.00	16.00	0.00				15.00		15.00
H6529	001	2	1	01	01	H6529_001_2	9			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					41.00	82.00	123.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.37	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
H6529	001	2	1	01	01	H6529_001_2	9			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											97.59	33	33	33				95.55	33	33	33				33	33	33																33		33								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
H6529	001	2	1	01	01	H6529_001_2	9			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 Brand, Specialty Tier, Select Care Drugs										35.00			35.00									35.00		35.00
H6529	001	2	1	01	01	H6529_001_2	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			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	0.00				0.00		0.00
H6529	002	0	1	01	01	H6529_002_0	9			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 Brand, 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	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					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 Brand, 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	9			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					41.00	82.00	123.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.37	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
H6529	002	0	1	01	01	H6529_002_0	9			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											96.86	29	29	29				96.36	29	29	29				29	29	29																29		29								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
H6529	002	0	1	01	01	H6529_002_0	9			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												30							30																								30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00			35.00									35.00		35.00
H6529	002	0	1	01	01	H6529_002_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			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	0.00				0.00		0.00
H6545	001	0	1	04	01	H6545_001_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										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	7			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
H6545	001	0	1	04	01	H6545_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	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
H6545	001	0	1	04	01	H6545_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				48.00	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
H6545	001	0	1	04	01	H6545_001_0	7			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
H6550	003	0	1	02	01	H6550_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			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	02	01	H6550_003_0	5			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																								
H6550	003	0	1	02	01	H6550_003_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											157.75	25	25	25				157.75	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
H6550	003	0	1	02	01	H6550_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											61.56	39	39	39				59.98	38	38	38										39	39	39				38	38	38			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
H6550	003	0	1	02	01	H6550_003_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, Select Care Drugs																								
H6550	003	0	1	02	01	H6550_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																								
H6550	007	0	1	02	01	H6550_007_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																								
H6550	007	0	1	02	01	H6550_007_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6550	007	0	1	02	01	H6550_007_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.26	25	25	25				164.26	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
H6550	007	0	1	02	01	H6550_007_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											68.49	38	38	38				66.68	37	37	37										38	38	38				37	37	37			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
H6550	007	0	1	02	01	H6550_007_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, Select Care Drugs																								
H6550	007	0	1	02	01	H6550_007_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																								
H6586	001	0	1	04	01	H6586_001_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				60.00	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
H6586	001	0	1	04	01	H6586_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				46.00	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
H6586	001	0	1	04	01	H6586_001_0	7			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
H6586	002	0	1	04	01	H6586_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	Preferred Generic, 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	6			Generic	4	11	3	2	2	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	10.00																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	10.00				4.00		4.00
H6586	002	0	1	04	01	H6586_002_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				79.00	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
H6586	002	0	1	04	01	H6586_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				41.00	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
H6586	002	0	1	04	01	H6586_002_0	6			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
H6586	003	0	1	04	01	H6586_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.00	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
H6586	003	0	1	04	01	H6586_003_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				39.00	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
H6586	003	0	1	04	01	H6586_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	26																				26																	26			26								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	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										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	7			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	006	0	1	04	01	H6586_006_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				74.00	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
H6586	006	0	1	04	01	H6586_006_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				38.00	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
H6586	006	0	1	04	01	H6586_006_0	7			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
H6622	001	0	1	01	01	H6622_001_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
H6622	001	0	1	01	01	H6622_001_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
H6622	001	0	1	01	01	H6622_001_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		95.00	35.00		35.00
H6622	001	0	1	01	01	H6622_001_0	4			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																								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
H6622	001	0	1	01	01	H6622_001_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
H6622	004	0	1	01	01	H6622_004_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
H6622	004	0	1	01	01	H6622_004_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
H6622	004	0	1	01	01	H6622_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		95.00	35.00		35.00
H6622	004	0	1	01	01	H6622_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H6622	004	0	1	01	01	H6622_004_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
H6622	007	0	1	01	01	H6622_007_0	3			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	3			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	3			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		95.00	35.00		35.00
H6622	007	0	1	01	01	H6622_007_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	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
H6622	007	0	1	01	01	H6622_007_0	3			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	013	0	1	02	01	H6622_013_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
H6622	013	0	1	02	01	H6622_013_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
H6622	013	0	1	02	01	H6622_013_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		95.00	35.00		35.00
H6622	013	0	1	02	01	H6622_013_0	4			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																								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
H6622	013	0	1	02	01	H6622_013_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
H6622	014	0	1	02	01	H6622_014_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
H6622	014	0	1	02	01	H6622_014_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
H6622	014	0	1	02	01	H6622_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		95.00	35.00		35.00
H6622	014	0	1	02	01	H6622_014_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H6622	014	0	1	02	01	H6622_014_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
H6622	017	0	1	01	01	H6622_017_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, 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	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, 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	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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H6622	017	0	1	01	01	H6622_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				93.00	43		43																								43		43				43		43			43			43								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	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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H6622	017	0	1	01	01	H6622_017_0	4			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	021	1	1	02	01	H6622_021_1	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
H6622	021	1	1	02	01	H6622_021_1	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
H6622	021	1	1	02	01	H6622_021_1	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		95.00	35.00		35.00
H6622	021	1	1	02	01	H6622_021_1	4			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																								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
H6622	021	1	1	02	01	H6622_021_1	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
H6622	021	2	1	02	01	H6622_021_2	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
H6622	021	2	1	02	01	H6622_021_2	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
H6622	021	2	1	02	01	H6622_021_2	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		95.00	35.00		35.00
H6622	021	2	1	02	01	H6622_021_2	4			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																								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
H6622	021	2	1	02	01	H6622_021_2	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
H6622	022	0	1	02	01	H6622_022_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
H6622	022	0	1	02	01	H6622_022_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
H6622	022	0	1	02	01	H6622_022_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		95.00	35.00		35.00
H6622	022	0	1	02	01	H6622_022_0	4			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																								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
H6622	022	0	1	02	01	H6622_022_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
H6622	023	0	1	02	01	H6622_023_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
H6622	023	0	1	02	01	H6622_023_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
H6622	023	0	1	02	01	H6622_023_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		95.00	35.00		35.00
H6622	023	0	1	02	01	H6622_023_0	4			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																								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
H6622	023	0	1	02	01	H6622_023_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
H6622	025	0	1	02	01	H6622_025_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
H6622	025	0	1	02	01	H6622_025_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
H6622	025	0	1	02	01	H6622_025_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		95.00	35.00		35.00
H6622	025	0	1	02	01	H6622_025_0	4			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																								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
H6622	025	0	1	02	01	H6622_025_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
H6622	026	0	1	02	01	H6622_026_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
H6622	026	0	1	02	01	H6622_026_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
H6622	026	0	1	02	01	H6622_026_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		95.00	35.00		35.00
H6622	026	0	1	02	01	H6622_026_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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		35.00
H6622	026	0	1	02	01	H6622_026_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
H6622	028	0	1	01	01	H6622_028_0	4			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
H6622	028	0	1	01	01	H6622_028_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
H6622	028	0	1	01	01	H6622_028_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		95.00	35.00		35.00
H6622	028	0	1	01	01	H6622_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				95.00	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		35.00
H6622	028	0	1	01	01	H6622_028_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
H6622	029	0	1	01	01	H6622_029_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, Select Care Drugs										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	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, Select Care Drugs										0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	029	0	1	01	01	H6622_029_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	44.00		132.00																									47.00		141.00				44.00		88.00				44.00				44.00		1.47				1.57	1.47	1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00
H6622	029	0	1	01	01	H6622_029_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	35		35																								44		44				35		35			35			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
H6622	029	0	1	01	01	H6622_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, Select Care Drugs										35.00						35.00			35.00			35.00		35.00
H6622	029	0	1	01	01	H6622_029_0	8			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				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	032	0	1	01	01	H6622_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		0.00				0.33	0.00	0.00	Preferred Generic, 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	4			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
H6622	032	0	1	01	01	H6622_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		95.00	35.00		35.00
H6622	032	0	1	01	01	H6622_032_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H6622	032	0	1	01	01	H6622_032_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
H6622	033	0	1	01	01	H6622_033_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
H6622	033	0	1	01	01	H6622_033_0	4			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
H6622	033	0	1	01	01	H6622_033_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		95.00	35.00		35.00
H6622	033	0	1	01	01	H6622_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		105.00	35.00		35.00
H6622	033	0	1	01	01	H6622_033_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
H6622	035	0	1	01	01	H6622_035_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
H6622	035	0	1	01	01	H6622_035_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
H6622	035	0	1	01	01	H6622_035_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		95.00	35.00		35.00
H6622	035	0	1	01	01	H6622_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H6622	035	0	1	01	01	H6622_035_0	4			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	036	0	1	01	01	H6622_036_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
H6622	036	0	1	01	01	H6622_036_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
H6622	036	0	1	01	01	H6622_036_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		95.00	35.00		35.00
H6622	036	0	1	01	01	H6622_036_0	4			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																								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		35.00
H6622	036	0	1	01	01	H6622_036_0	4			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	037	0	1	01	01	H6622_037_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
H6622	037	0	1	01	01	H6622_037_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
H6622	037	0	1	01	01	H6622_037_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		95.00	35.00		35.00
H6622	037	0	1	01	01	H6622_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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		35.00
H6622	037	0	1	01	01	H6622_037_0	4			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	047	0	1	01	01	H6622_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
H6622	047	0	1	01	01	H6622_047_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
H6622	047	0	1	01	01	H6622_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		95.00	35.00		35.00
H6622	047	0	1	01	01	H6622_047_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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		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					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	054	0	1	01	01	H6622_054_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	054	0	1	01	01	H6622_054_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
H6622	054	0	1	01	01	H6622_054_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		95.00	35.00		35.00
H6622	054	0	1	01	01	H6622_054_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	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		35.00
H6622	054	0	1	01	01	H6622_054_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
H6622	055	0	1	01	01	H6622_055_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
H6622	055	0	1	01	01	H6622_055_0	4			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
H6622	055	0	1	01	01	H6622_055_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		95.00	35.00		35.00
H6622	055	0	1	01	01	H6622_055_0	4			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																								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		35.00
H6622	055	0	1	01	01	H6622_055_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
H6622	056	0	1	01	01	H6622_056_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
H6622	056	0	1	01	01	H6622_056_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
H6622	056	0	1	01	01	H6622_056_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		95.00	35.00		35.00
H6622	056	0	1	01	01	H6622_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H6622	056	0	1	01	01	H6622_056_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
H6622	057	0	1	02	01	H6622_057_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
H6622	057	0	1	02	01	H6622_057_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
H6622	057	0	1	02	01	H6622_057_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		95.00	35.00		35.00
H6622	057	0	1	02	01	H6622_057_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H6622	057	0	1	02	01	H6622_057_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
H6622	060	0	1	02	01	H6622_060_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
H6622	060	0	1	02	01	H6622_060_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
H6622	060	0	1	02	01	H6622_060_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		95.00	35.00		35.00
H6622	060	0	1	02	01	H6622_060_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				92.00	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		35.00
H6622	060	0	1	02	01	H6622_060_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
H6622	061	0	1	02	01	H6622_061_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
H6622	061	0	1	02	01	H6622_061_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
H6622	061	0	1	02	01	H6622_061_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		95.00	35.00		35.00
H6622	061	0	1	02	01	H6622_061_0	4			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																								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		35.00
H6622	061	0	1	02	01	H6622_061_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
H6622	063	0	1	01	01	H6622_063_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
H6622	063	0	1	01	01	H6622_063_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
H6622	063	0	1	01	01	H6622_063_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		95.00	35.00		35.00
H6622	063	0	1	01	01	H6622_063_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	37		37																								37		37				37		37			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
H6622	063	0	1	01	01	H6622_063_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
H6622	066	0	1	01	01	H6622_066_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
H6622	066	0	1	01	01	H6622_066_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
H6622	066	0	1	01	01	H6622_066_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		95.00	35.00		35.00
H6622	066	0	1	01	01	H6622_066_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	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		105.00	35.00		35.00
H6622	066	0	1	01	01	H6622_066_0	4			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	071	0	1	01	01	H6622_071_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, 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	4			Generic	4	11	1	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, Select Care Drugs										9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H6622	071	0	1	01	01	H6622_071_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, Select Care Drugs										35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H6622	071	0	1	01	01	H6622_071_0	4			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																								50		50				50		50			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		35.00
H6622	071	0	1	01	01	H6622_071_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
H6622	071	0	1	01	01	H6622_071_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
H6622	073	0	1	02	01	H6622_073_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
H6622	073	0	1	02	01	H6622_073_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	7.00		21.00																									20.00		60.00				7.00		0.00				7.00				7.00		0.23				0.67	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00		21.00				20.00		60.00	7.00		0.00	7.00		7.00
H6622	073	0	1	02	01	H6622_073_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		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		70.00	35.00		35.00
H6622	073	0	1	02	01	H6622_073_0	4			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																								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
H6622	073	0	1	02	01	H6622_073_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
H6622	075	0	1	01	01	H6622_075_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
H6622	075	0	1	01	01	H6622_075_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
H6622	075	0	1	01	01	H6622_075_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		95.00	35.00		35.00
H6622	075	0	1	01	01	H6622_075_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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
H6622	075	0	1	01	01	H6622_075_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
H6622	079	0	1	01	01	H6622_079_0	5		N	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	079	0	1	01	01	H6622_079_0	5		N	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
H6622	079	0	1	01	01	H6622_079_0	5		N	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		70.00	35.00		35.00
H6622	079	0	1	01	01	H6622_079_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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
H6622	079	0	1	01	01	H6622_079_0	5		N	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	081	0	1	01	01	H6622_081_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
H6622	081	0	1	01	01	H6622_081_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
H6622	081	0	1	01	01	H6622_081_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		95.00	35.00		35.00
H6622	081	0	1	01	01	H6622_081_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				92.00	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		105.00	35.00		35.00
H6622	081	0	1	01	01	H6622_081_0	4			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	082	0	1	01	01	H6622_082_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
H6622	082	0	1	01	01	H6622_082_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
H6622	082	0	1	01	01	H6622_082_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	43.00		129.00																									47.00		141.00				43.00		86.00				43.00				43.00		1.43				1.57	1.43	1.39	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
H6622	082	0	1	01	01	H6622_082_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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		105.00	35.00		35.00
H6622	082	0	1	01	01	H6622_082_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
H6622	083	0	1	01	01	H6622_083_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
H6622	083	0	1	01	01	H6622_083_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
H6622	083	0	1	01	01	H6622_083_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		95.00	35.00		35.00
H6622	083	0	1	01	01	H6622_083_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H6622	083	0	1	01	01	H6622_083_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
H6622	084	0	1	01	01	H6622_084_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
H6622	084	0	1	01	01	H6622_084_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
H6622	084	0	1	01	01	H6622_084_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		95.00	35.00		35.00
H6622	084	0	1	01	01	H6622_084_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	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		35.00
H6622	084	0	1	01	01	H6622_084_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
H6622	085	0	1	01	01	H6622_085_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
H6622	085	0	1	01	01	H6622_085_0	4			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	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		95.00	35.00		35.00
H6622	085	0	1	01	01	H6622_085_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	42		42																								42		42				42		42			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
H6622	085	0	1	01	01	H6622_085_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
H6622	090	0	1	01	01	H6622_090_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
H6622	090	0	1	01	01	H6622_090_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
H6622	090	0	1	01	01	H6622_090_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		95.00	35.00		35.00
H6622	090	0	1	01	01	H6622_090_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	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		35.00
H6622	090	0	1	01	01	H6622_090_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
H6622	091	0	1	01	01	H6622_091_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
H6622	091	0	1	01	01	H6622_091_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
H6622	091	0	1	01	01	H6622_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		95.00	35.00		35.00
H6622	091	0	1	01	01	H6622_091_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	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		35.00
H6622	091	0	1	01	01	H6622_091_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
H6622	095	0	1	01	01	H6622_095_0	4			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	095	0	1	01	01	H6622_095_0	4			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	095	0	1	01	01	H6622_095_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		95.00	35.00		35.00
H6622	095	0	1	01	01	H6622_095_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	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		35.00
H6622	095	0	1	01	01	H6622_095_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
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																								
H6706	001	0	1	02	01	H6706_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																								
H6706	001	0	1	02	01	H6706_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																								
H6706	001	0	1	02	01	H6706_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
H6706	001	0	1	02	01	H6706_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H6706	001	0	1	02	01	H6706_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				199.00	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
H6713	001	0	1	04	01	H6713_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																								
H6713	001	0	1	04	01	H6713_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6713	001	0	1	04	01	H6713_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											154.67	25	25	25				154.67	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
H6713	001	0	1	04	01	H6713_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											56.01	41	41	41				54.65	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
H6713	001	0	1	04	01	H6713_001_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, Select Care Drugs																								
H6713	001	0	1	04	01	H6713_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																								
H6713	002	0	1	04	01	H6713_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																								
H6713	002	0	1	04	01	H6713_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6713	002	0	1	04	01	H6713_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											148.70	25	25	25				148.70	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
H6713	002	0	1	04	01	H6713_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											61.42	50	50	50				61.42	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	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, Select Care Drugs																								
H6713	002	0	1	04	01	H6713_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																								
H6723	001	1	1	01	01	H6723_001_1	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	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	6			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	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	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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.04	50	50	50				53.28	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
H6723	001	1	1	01	01	H6723_001_1	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																								
H6723	001	2	1	01	01	H6723_001_2	7			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	7			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	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	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	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.04	50	50	50				53.28	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
H6723	001	2	1	01	01	H6723_001_2	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																								
H6723	001	3	1	01	01	H6723_001_3	7			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	7			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	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	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	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.04	50	50	50				53.28	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
H6723	001	3	1	01	01	H6723_001_3	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																								
H6723	002	1	1	01	01	H6723_002_1	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.34	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										35.00	70.00	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	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.34	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										35.00	70.00	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	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.34	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										35.00	70.00	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	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.97	50	50	50				40.17	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
H6723	003	1	1	01	01	H6723_003_1	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.97	50	50	50				40.17	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
H6723	003	2	1	01	01	H6723_003_2	5			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	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	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	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	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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.97	50	50	50				40.17	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
H6723	003	3	1	01	01	H6723_003_3	5			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	02	01	H6723_005_1	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	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	02	01	H6723_005_1	6			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	02	01	H6723_005_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	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	02	01	H6723_005_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											49.56	50	50	50				47.32	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
H6723	005	1	1	02	01	H6723_005_1	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																								
H6723	005	2	1	02	01	H6723_005_2	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	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	02	01	H6723_005_2	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	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	02	01	H6723_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								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	02	01	H6723_005_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.56	50	50	50				47.32	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
H6723	005	2	1	02	01	H6723_005_2	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																								
H6723	006	6	1	02	01	H6723_006_6	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	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	02	01	H6723_006_6	5			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	02	01	H6723_006_6	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	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	02	01	H6723_006_6	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.99	50	50	50				44.69	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
H6723	006	6	1	02	01	H6723_006_6	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, Select Care Drugs																								
H6723	006	6	1	02	01	H6723_006_6	5			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	02	01	H6723_006_7	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	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	02	01	H6723_006_7	5			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	02	01	H6723_006_7	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	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	02	01	H6723_006_7	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.99	50	50	50				44.69	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
H6723	006	7	1	02	01	H6723_006_7	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, Select Care Drugs																								
H6723	006	7	1	02	01	H6723_006_7	5			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																								
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	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					10.00	20.00	0.00																20.00				20.00			0.67	0.33	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	10.00	20.00	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					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										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					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
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										35.00			35.00			35.00						35.00		35.00
H6743	001	0	1	04	01	H6743_001_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	001	0	1	04	01	H6743_001_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										8.00		16.00						16.00				8.00		8.00
H6743	001	0	1	04	01	H6743_001_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	001	0	1	04	01	H6743_001_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										35.00		70.00						70.00				35.00		35.00
H6743	001	0	1	04	01	H6743_001_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																								
H6743	001	0	1	04	01	H6743_001_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																								
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										8.00		16.00						16.00				8.00		8.00
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										35.00		70.00						70.00				35.00		35.00
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																								
H6743	025	0	1	04	01	H6743_025_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																								
H6743	025	0	1	04	01	H6743_025_0	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										8.00		16.00						16.00				8.00		8.00
H6743	025	0	1	04	01	H6743_025_0	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	025	0	1	04	01	H6743_025_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										35.00		70.00						70.00				35.00		35.00
H6743	025	0	1	04	01	H6743_025_0	12			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	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																								
H6743	026	0	1	04	01	H6743_026_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	026	0	1	04	01	H6743_026_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										8.00		16.00						16.00				8.00		8.00
H6743	026	0	1	04	01	H6743_026_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	026	0	1	04	01	H6743_026_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										35.00		70.00						70.00				35.00		35.00
H6743	026	0	1	04	01	H6743_026_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																								
H6743	026	0	1	04	01	H6743_026_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																								
H6743	028	0	1	04	01	H6743_028_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	028	0	1	04	01	H6743_028_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										8.00		16.00						16.00				8.00		8.00
H6743	028	0	1	04	01	H6743_028_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	028	0	1	04	01	H6743_028_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										35.00		70.00						70.00				35.00		35.00
H6743	028	0	1	04	01	H6743_028_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																								
H6743	028	0	1	04	01	H6743_028_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																								
H6743	030	0	1	04	01	H6743_030_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	030	0	1	04	01	H6743_030_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										8.00		16.00						16.00				8.00		8.00
H6743	030	0	1	04	01	H6743_030_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	030	0	1	04	01	H6743_030_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										35.00		70.00						70.00				35.00		35.00
H6743	030	0	1	04	01	H6743_030_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																								
H6743	030	0	1	04	01	H6743_030_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																								
H6813	001	0	1	04	01	H6813_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
H6813	001	0	1	04	01	H6813_001_0	5			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H6813	001	0	1	04	01	H6813_001_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.00	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
H6813	001	0	1	04	01	H6813_001_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				39.00	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
H6813	001	0	1	04	01	H6813_001_0	5			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.00	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
H6813	002	0	1	04	01	H6813_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				38.00	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
H6813	002	0	1	04	01	H6813_002_0	7			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
H6815	038	0	1	02	01	H6815_038_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																								
H6815	038	0	1	02	01	H6815_038_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6815	038	0	1	02	01	H6815_038_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.75	25	25	25				155.75	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
H6815	038	0	1	02	01	H6815_038_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											66.91	43	43	43				65.35	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
H6815	038	0	1	02	01	H6815_038_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, Select Care Drugs																								
H6815	038	0	1	02	01	H6815_038_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																								
H6815	039	0	1	02	01	H6815_039_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																								
H6815	039	0	1	02	01	H6815_039_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6815	039	0	1	02	01	H6815_039_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											151.39	25	25	25				151.39	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
H6815	039	0	1	02	01	H6815_039_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											44.27	37	37	37				44.27	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
H6815	039	0	1	02	01	H6815_039_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, Select Care Drugs																								
H6815	039	0	1	02	01	H6815_039_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																								
H6815	040	0	1	02	01	H6815_040_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																								
H6815	040	0	1	02	01	H6815_040_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6815	040	0	1	02	01	H6815_040_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.79	25	25	25				153.79	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
H6815	040	0	1	02	01	H6815_040_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											44.72	37	37	37				44.72	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
H6815	040	0	1	02	01	H6815_040_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, Select Care Drugs																								
H6815	040	0	1	02	01	H6815_040_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																								
H6830	001	0	1	04	01	H6830_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																								
H6830	001	0	1	04	01	H6830_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H6830	001	0	1	04	01	H6830_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											159.75	25	25	25				159.75	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
H6830	001	0	1	04	01	H6830_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											60.61	40	40	40				59.10	39	39	39										40	40	40				39	39	39			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
H6830	001	0	1	04	01	H6830_001_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, Select Care Drugs																								
H6830	001	0	1	04	01	H6830_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																								
H6832	001	0	1	01	01	H6832_001_0	6			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	6			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	6			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	6			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
H6832	001	0	1	01	01	H6832_001_0	6			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	7			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	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																			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	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, 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	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, 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	7			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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H6832	004	0	1	02	01	H6832_004_0	7			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	004	0	1	02	01	H6832_004_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																								
H6832	004	0	1	02	01	H6832_004_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
H6832	004	0	1	02	01	H6832_004_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
H6832	004	0	1	02	01	H6832_004_0	7			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																								
H6847	001	0	1	02	01	H6847_001_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																								
H6847	001	0	1	02	01	H6847_001_0	7			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	10.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6847	001	0	1	02	01	H6847_001_0	7			Preferred Brand	4	11	3	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
H6847	001	0	1	02	01	H6847_001_0	7			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	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	7			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	9			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	9			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	002	0	1	01	01	H6851_002_0	9			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	9			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										35.00		105.00				35.00		105.00				35.00		35.00
H6851	002	0	1	01	01	H6851_002_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																								
H6851	003	0	1	01	01	H6851_003_0	9			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	9			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	9			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	9			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										35.00		105.00				35.00		105.00				35.00		35.00
H6851	003	0	1	01	01	H6851_003_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																								
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										35.00		105.00				35.00		105.00				35.00		35.00
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					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6852	001	0	1	01	01	H6852_001_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										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	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																			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
H6852	001	0	1	01	01	H6852_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				77.00	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
H6852	001	0	1	01	01	H6852_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				39.00	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
H6852	001	0	1	01	01	H6852_001_0	7			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
H6852	002	0	1	01	01	H6852_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										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	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																			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
H6852	002	0	1	01	01	H6852_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				80.00	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
H6852	002	0	1	01	01	H6852_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				42.00	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
H6852	002	0	1	01	01	H6852_002_0	7			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
H6870	001	0	1	48	05	H6870_001_0	3			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	3			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	3			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	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																								
H6874	001	0	1	04	01	H6874_001_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																								
H6874	001	0	1	04	01	H6874_001_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
H6874	001	0	1	04	01	H6874_001_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										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	9			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1755.00	30																				30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H6876	001	0	1	04	01	H6876_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
H6876	001	0	1	04	01	H6876_001_0	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				82.00	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
H6876	001	0	1	04	01	H6876_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				568.07	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
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	5	5	5																		0	0	0															5			5								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										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	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.08	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	70.00				35.00		35.00
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				461.24	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H6876	003	0	1	04	01	H6876_003_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, 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	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				67.25	33	33	33																		33	33	33															33			33								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
H6876	003	0	1	04	01	H6876_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				477.73	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
H6876	003	0	1	04	01	H6876_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	Preferred 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	004	0	1	04	01	H6876_004_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	Preferred Generic, 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	6			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	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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, 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	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				82.11	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
H6876	004	0	1	04	01	H6876_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				570.34	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H6876	005	0	1	04	01	H6876_005_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, 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	5			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	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																			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										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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.77	33	33	33																		33	33	33															33			33								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
H6876	005	0	1	04	01	H6876_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				503.62	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
H6876	005	0	1	04	01	H6876_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
H6876	006	0	1	04	01	H6876_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
H6876	006	0	1	04	01	H6876_006_0	12			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																								
H6876	006	0	1	04	01	H6876_006_0	12			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										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	12			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				64.70	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	70.00				35.00		35.00
H6876	006	0	1	04	01	H6876_006_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				451.65	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00						0.00						0.00		0.00
H6876	006	0	1	04	01	H6876_006_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	007	0	1	04	01	H6876_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	Preferred 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	007	0	1	04	01	H6876_007_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	007	0	1	04	01	H6876_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, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	007	0	1	04	01	H6876_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				71.41	33	33	33																		33	33	33															33			33								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
H6876	007	0	1	04	01	H6876_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				513.20	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
H6876	007	0	1	04	01	H6876_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	Preferred 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	008	0	1	04	01	H6876_008_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
H6876	008	0	1	04	01	H6876_008_0	12			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																								
H6876	008	0	1	04	01	H6876_008_0	12			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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	008	0	1	04	01	H6876_008_0	12			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				68.08	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	70.00				35.00		35.00
H6876	008	0	1	04	01	H6876_008_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				464.84	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										0.00						0.00						0.00		0.00
H6876	008	0	1	04	01	H6876_008_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	009	0	1	04	01	H6876_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
H6876	009	0	1	04	01	H6876_009_0	10			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	009	0	1	04	01	H6876_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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, 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	009	0	1	04	01	H6876_009_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				83.22	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
H6876	009	0	1	04	01	H6876_009_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				577.22	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H6898	001	0	1	04	01	H6898_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, Select Care Drugs																								
H6898	001	0	1	04	01	H6898_001_0	11			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	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, 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	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										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	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				881.92	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H6898	001	0	1	04	01	H6898_001_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																								
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	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, Select Care Drugs										35.00	70.00	105.00				35.00	70.00	105.00				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										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
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	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											47.61	25	25	25				44.31	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	70.00	70.00				35.00		35.00
H6910	001	0	1	01	01	H6910_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											85.63	50	50	50				94.83	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	70.00				35.00		35.00
H6910	001	0	1	01	01	H6910_001_0	6			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	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											66.07	25	25	25				60.71	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
H6910	005	0	1	01	01	H6910_005_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											91.07	50	50	50				98.00	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	70.00				35.00		35.00
H6910	005	0	1	01	01	H6910_005_0	6			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
H6959	002	0	1	01	01	H6959_002_0	4			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																								
H6959	002	0	1	01	01	H6959_002_0	4			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																								
H6959	002	0	1	01	01	H6959_002_0	4			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
H6959	002	0	1	01	01	H6959_002_0	4			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
H6959	002	0	1	01	01	H6959_002_0	4			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31					29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H6959	003	0	1	01	01	H6959_003_0	4			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																								
H6959	003	0	1	01	01	H6959_003_0	4			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																								
H6959	003	0	1	01	01	H6959_003_0	4			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
H6959	003	0	1	01	01	H6959_003_0	4			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
H6959	003	0	1	01	01	H6959_003_0	4			Specialty Tier	4	11	1	1	5	1	010		10	000		1	30															10	31					29																																						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H6988	001	0	1	01	01	H6988_001_0	6			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										0.00		0.00						0.00				0.00		0.00
H6988	001	0	1	01	01	H6988_001_0	6			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 Drug, Specialty Tier										15.00		45.00						37.50				15.00		15.00
H6988	001	0	1	01	01	H6988_001_0	6			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 Drug, Specialty Tier										35.00		105.00						105.00				35.00		35.00
H6988	001	0	1	01	01	H6988_001_0	6			Non-Preferred Drug	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 Drug, Specialty Tier										35.00		105.00						105.00				35.00		35.00
H6988	001	0	1	01	01	H6988_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				385.62	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00												35.00		35.00
H7006	003	0	1	04	01	H7006_003_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	003	0	1	04	01	H7006_003_0	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										8.00		16.00						16.00				8.00		8.00
H7006	003	0	1	04	01	H7006_003_0	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
H7006	003	0	1	04	01	H7006_003_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										35.00		70.00						70.00				35.00		35.00
H7006	003	0	1	04	01	H7006_003_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	003	0	1	04	01	H7006_003_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																								
H7006	007	0	1	04	01	H7006_007_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	007	0	1	04	01	H7006_007_0	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										8.00		16.00						16.00				8.00		8.00
H7006	007	0	1	04	01	H7006_007_0	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
H7006	007	0	1	04	01	H7006_007_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										35.00		70.00						70.00				35.00		35.00
H7006	007	0	1	04	01	H7006_007_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	007	0	1	04	01	H7006_007_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																								
H7006	010	0	1	04	01	H7006_010_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	010	0	1	04	01	H7006_010_0	11			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										12.00		24.00						24.00				12.00		12.00
H7006	010	0	1	04	01	H7006_010_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	010	0	1	04	01	H7006_010_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										35.00		70.00						70.00				35.00		35.00
H7006	010	0	1	04	01	H7006_010_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	010	0	1	04	01	H7006_010_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																								
H7006	015	0	1	04	01	H7006_015_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	015	0	1	04	01	H7006_015_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										0.00		0.00						0.00				0.00		0.00
H7006	015	0	1	04	01	H7006_015_0	11			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	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										35.00		70.00						70.00				35.00		35.00
H7006	015	0	1	04	01	H7006_015_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	015	0	1	04	01	H7006_015_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																								
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										0.00		0.00						0.00				0.00		0.00
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										35.00		70.00						70.00				35.00		35.00
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																								
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										0.00		0.00						0.00				0.00		0.00
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	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	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										35.00		70.00						70.00				35.00		35.00
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																								
H7006	022	0	1	04	01	H7006_022_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	022	0	1	04	01	H7006_022_0	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										8.00		16.00						16.00				8.00		8.00
H7006	022	0	1	04	01	H7006_022_0	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
H7006	022	0	1	04	01	H7006_022_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										35.00		70.00						70.00				35.00		35.00
H7006	022	0	1	04	01	H7006_022_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	022	0	1	04	01	H7006_022_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																								
H7020	010	1	1	01	01	H7020_010_1	4			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
H7020	010	1	1	01	01	H7020_010_1	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	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	010	1	1	01	01	H7020_010_1	4			Preferred Brand	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	010	1	1	01	01	H7020_010_1	4			Non-Preferred Drug	4	11	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	010	1	1	01	01	H7020_010_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											944.65	33						692.12	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
H7020	010	2	1	01	01	H7020_010_2	4			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
H7020	010	2	1	01	01	H7020_010_2	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	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	010	2	1	01	01	H7020_010_2	4			Preferred Brand	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	010	2	1	01	01	H7020_010_2	4			Non-Preferred Drug	4	11	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	010	2	1	01	01	H7020_010_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											944.65	33						692.12	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
H7020	010	3	1	01	01	H7020_010_3	4			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
H7020	010	3	1	01	01	H7020_010_3	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	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	010	3	1	01	01	H7020_010_3	4			Preferred Brand	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	010	3	1	01	01	H7020_010_3	4			Non-Preferred Drug	4	11	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	010	3	1	01	01	H7020_010_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											944.65	33						692.12	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
H7020	011	1	1	01	01	H7020_011_1	4			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
H7020	011	1	1	01	01	H7020_011_1	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	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	011	1	1	01	01	H7020_011_1	4			Preferred Brand	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	011	1	1	01	01	H7020_011_1	4			Non-Preferred Drug	4	11	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	011	1	1	01	01	H7020_011_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											943.91	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
H7020	011	2	1	01	01	H7020_011_2	4			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
H7020	011	2	1	01	01	H7020_011_2	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	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	011	2	1	01	01	H7020_011_2	4			Preferred Brand	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	011	2	1	01	01	H7020_011_2	4			Non-Preferred Drug	4	11	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	011	2	1	01	01	H7020_011_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											943.91	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
H7020	011	3	1	01	01	H7020_011_3	4			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
H7020	011	3	1	01	01	H7020_011_3	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	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	011	3	1	01	01	H7020_011_3	4			Preferred Brand	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	011	3	1	01	01	H7020_011_3	4			Non-Preferred Drug	4	11	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	011	3	1	01	01	H7020_011_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											943.91	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
H7028	001	0	1	04	01	H7028_001_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.00	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
H7028	001	0	1	04	01	H7028_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				39.00	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
H7028	001	0	1	04	01	H7028_001_0	7			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
H7028	002	0	1	04	01	H7028_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				75.00	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
H7028	002	0	1	04	01	H7028_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				41.00	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
H7028	002	0	1	04	01	H7028_002_0	7			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
H7063	001	0	1	04	01	H7063_001_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	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										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
H7063	001	0	1	04	01	H7063_001_0	7			Generic	4	01	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					5.00	10.00	10.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	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	0.00	0.00	0.00	10.00		10.00
H7063	001	0	1	04	01	H7063_001_0	7			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				47.00	94.00	94.00				47.00				47.00			1.57	1.40		1.57	1.57	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
H7063	001	0	1	04	01	H7063_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											97.05	33	33	33				74.99	31	31	31										33	33	33				31	31	31			33			33								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
H7063	001	0	1	04	01	H7063_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											462.07	33						475.27	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	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										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
H7063	006	0	1	04	01	H7063_006_0	7			Generic	4	01	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					5.00	10.00	10.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	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	0.00	0.00	0.00	10.00		10.00
H7063	006	0	1	04	01	H7063_006_0	7			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				47.00	94.00	94.00				47.00				47.00			1.57	1.40		1.57	1.57	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
H7063	006	0	1	04	01	H7063_006_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											99.36	33	33	33				84.12	31	31	31										33	33	33				31	31	31			33			33								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
H7063	006	0	1	04	01	H7063_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											508.50	33						526.35	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7063	007	0	1	04	01	H7063_007_0	8			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	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										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
H7063	007	0	1	04	01	H7063_007_0	8			Generic	4	01	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					5.00	10.00	10.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	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	0.00	0.00	0.00	10.00		10.00
H7063	007	0	1	04	01	H7063_007_0	8			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				47.00	94.00	94.00				47.00				47.00			1.57	1.40		1.57	1.57	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
H7063	007	0	1	04	01	H7063_007_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											95.58	33	33	33				72.63	31	31	31										33	33	33				31	31	31			33			33								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
H7063	007	0	1	04	01	H7063_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											482.94	33						506.02	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7063	012	0	1	04	01	H7063_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								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										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
H7063	012	0	1	04	01	H7063_012_0	7			Generic	4	01	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					5.00	10.00	10.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	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	0.00	0.00	0.00	10.00		10.00
H7063	012	0	1	04	01	H7063_012_0	7			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				47.00	94.00	94.00				47.00				47.00			1.57	1.40		1.57	1.57	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
H7063	012	0	1	04	01	H7063_012_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											81.20	33	33	33				62.97	31	31	31										33	33	33				31	31	31			33			33								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
H7063	012	0	1	04	01	H7063_012_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											505.76	33						418.31	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7074	001	0	1	04	01	H7074_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, 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	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										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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				337.19	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	8			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																								
H7093	002	0	1	04	01	H7093_002_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																								
H7093	002	0	1	04	01	H7093_002_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																								
H7093	002	0	1	04	01	H7093_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.44	25	25	25				46.75	20	20	20				20	20	20															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	70.00				35.00		35.00
H7093	002	0	1	04	01	H7093_002_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											44.64	35	35	35				44.64	35	35	35				35	35	35															35			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
H7093	002	0	1	04	01	H7093_002_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																								
H7093	002	0	1	04	01	H7093_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
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										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	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										4.00	8.00	12.00				4.00	8.00	12.00				4.00		4.00
H7115	001	0	1	01	01	H7115_001_0	5			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				62.21	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
H7115	001	0	1	01	01	H7115_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				58.08	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
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				412.31	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7147	001	0	1	01	01	H7147_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
H7147	001	0	1	01	01	H7147_001_0	5			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H7147	001	0	1	01	01	H7147_001_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				76.00	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
H7147	001	0	1	01	01	H7147_001_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				42.00	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
H7147	001	0	1	01	01	H7147_001_0	5			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
H7147	004	0	1	01	01	H7147_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7147	004	0	1	01	01	H7147_004_0	7			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	01	01	H7147_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				79.00	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
H7147	004	0	1	01	01	H7147_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				43.00	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
H7147	004	0	1	01	01	H7147_004_0	7			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
H7147	005	0	1	01	01	H7147_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7147	005	0	1	01	01	H7147_005_0	7			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
H7147	005	0	1	01	01	H7147_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.00	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
H7147	005	0	1	01	01	H7147_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				37.00	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
H7147	005	0	1	01	01	H7147_005_0	7			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
H7149	001	0	1	02	01	H7149_001_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7149	001	0	1	02	01	H7149_001_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7149	001	0	1	02	01	H7149_001_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.77	24	24	24				109.71	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
H7149	001	0	1	02	01	H7149_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.84	25	25	25				31.16	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
H7149	001	0	1	02	01	H7149_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.85	25						806.03	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
H7149	008	0	1	02	01	H7149_008_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7149	008	0	1	02	01	H7149_008_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7149	008	0	1	02	01	H7149_008_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.03	24	24	24				90.25	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
H7149	008	0	1	02	01	H7149_008_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.59	25	25	25				36.54	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
H7149	008	0	1	02	01	H7149_008_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											655.33	25						647.69	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
H7149	009	0	1	02	01	H7149_009_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7149	009	0	1	02	01	H7149_009_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7149	009	0	1	02	01	H7149_009_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.54	24	24	24				98.07	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
H7149	009	0	1	02	01	H7149_009_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.57	25	25	25				31.59	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
H7149	009	0	1	02	01	H7149_009_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											743.80	25						702.17	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
H7151	001	0	1	01	01	H7151_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
H7151	001	0	1	01	01	H7151_001_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																			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
H7151	001	0	1	01	01	H7151_001_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H7151	001	0	1	01	01	H7151_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				49.00	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
H7151	001	0	1	01	01	H7151_001_0	8			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
H7151	003	0	1	01	01	H7151_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
H7151	003	0	1	01	01	H7151_003_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	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
H7151	003	0	1	01	01	H7151_003_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	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	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7151	003	0	1	01	01	H7151_003_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				48.00	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
H7151	003	0	1	01	01	H7151_003_0	8			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
H7163	002	0	1	02	01	H7163_002_0	4			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	4			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	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					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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											37.59	50	50	50				43.69	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
H7163	002	0	1	02	01	H7163_002_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											774.28	33						383.04	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7163	003	0	1	02	01	H7163_003_0	6		N	Preferred Generic	2	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																								
H7163	003	0	1	02	01	H7163_003_0	6		N	Generic	2	01	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.57	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7163	003	0	1	02	01	H7163_003_0	6		N	Preferred Brand	2	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				64.33	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
H7163	003	0	1	02	01	H7163_003_0	6		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.18	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
H7163	003	0	1	02	01	H7163_003_0	6		N	Specialty Tier	2	11	1	1	5	1	010		01	010		1	30								30						30		31				846.77	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7163	004	0	1	02	01	H7163_004_0	4			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	4			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	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					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	004	0	1	02	01	H7163_004_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											45.62	50	50	50				46.07	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
H7163	004	0	1	02	01	H7163_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											929.99	33						615.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7163	005	0	1	02	01	H7163_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								10.00	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	4			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	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					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	005	0	1	02	01	H7163_005_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.04	50	50	50				64.19	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
H7163	005	0	1	02	01	H7163_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											783.49	29						400.63	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7169	001	0	1	04	01	H7169_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																								
H7169	001	0	1	04	01	H7169_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H7169	001	0	1	04	01	H7169_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											158.97	25	25	25				158.97	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
H7169	001	0	1	04	01	H7169_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											60.88	41	41	41				60.88	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
H7169	001	0	1	04	01	H7169_001_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, Select Care Drugs																								
H7169	001	0	1	04	01	H7169_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																								
H7169	003	0	1	04	01	H7169_003_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								19.00	38.00	57.00					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7169	003	0	1	04	01	H7169_003_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7169	003	0	1	04	01	H7169_003_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											116.66	20	20	20				116.66	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
H7169	003	0	1	04	01	H7169_003_0	6		N	Non-Preferred Drug	3	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	200.00				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
H7169	003	0	1	04	01	H7169_003_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, Select Care Drugs																								
H7169	003	0	1	04	01	H7169_003_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	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	5			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	5			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	5			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															
H7199	001	0	1	04	01	H7199_001_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										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	7			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
H7199	001	0	1	04	01	H7199_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				74.00	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
H7199	001	0	1	04	01	H7199_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				40.00	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
H7199	001	0	1	04	01	H7199_001_0	7			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
H7199	002	0	1	04	01	H7199_002_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
H7199	002	0	1	04	01	H7199_002_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																			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
H7199	002	0	1	04	01	H7199_002_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				65.00	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
H7199	002	0	1	04	01	H7199_002_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				49.00	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
H7199	002	0	1	04	01	H7199_002_0	8			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
H7220	004	0	1	02	01	H7220_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	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																								
H7220	004	0	1	02	01	H7220_004_0	5			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				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7220	004	0	1	02	01	H7220_004_0	5			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																			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
H7220	004	0	1	02	01	H7220_004_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				89.12	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		35.00
H7220	004	0	1	02	01	H7220_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																								
H7220	004	0	1	02	01	H7220_004_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																								
H7220	009	1	1	01	01	H7220_009_1	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, Select Care Drugs																								
H7220	009	1	1	01	01	H7220_009_1	5			Generic	4	01	1	2	2	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	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																								
H7220	009	1	1	01	01	H7220_009_1	5			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																			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
H7220	009	1	1	01	01	H7220_009_1	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				94.39	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		35.00
H7220	009	1	1	01	01	H7220_009_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, Select Care Drugs																								
H7220	009	1	1	01	01	H7220_009_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 Drug, Specialty Tier, Select Care Drugs																								
H7220	009	2	1	01	01	H7220_009_2	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, Select Care Drugs																								
H7220	009	2	1	01	01	H7220_009_2	5			Generic	4	01	1	2	2	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	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																								
H7220	009	2	1	01	01	H7220_009_2	5			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																			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
H7220	009	2	1	01	01	H7220_009_2	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				94.39	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		35.00
H7220	009	2	1	01	01	H7220_009_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, Select Care Drugs																								
H7220	009	2	1	01	01	H7220_009_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 Drug, Specialty Tier, Select Care Drugs																								
H7220	009	3	1	01	01	H7220_009_3	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, Select Care Drugs																								
H7220	009	3	1	01	01	H7220_009_3	5			Generic	4	01	1	2	2	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	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																								
H7220	009	3	1	01	01	H7220_009_3	5			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																			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
H7220	009	3	1	01	01	H7220_009_3	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				94.39	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		35.00
H7220	009	3	1	01	01	H7220_009_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, Select Care Drugs																								
H7220	009	3	1	01	01	H7220_009_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 Drug, Specialty Tier, Select Care Drugs																								
H7220	010	0	1	01	01	H7220_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7220	010	0	1	01	01	H7220_010_0	5			Generic	4	01	1	2	2	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	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																								
H7220	010	0	1	01	01	H7220_010_0	5			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																			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
H7220	010	0	1	01	01	H7220_010_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				99.37	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		35.00
H7220	010	0	1	01	01	H7220_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, Select Care Drugs																								
H7220	010	0	1	01	01	H7220_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7220	011	0	1	02	01	H7220_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7220	011	0	1	02	01	H7220_011_0	5			Generic	4	01	1	2	2	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	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																								
H7220	011	0	1	02	01	H7220_011_0	5			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																			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
H7220	011	0	1	02	01	H7220_011_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				87.07	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		35.00
H7220	011	0	1	02	01	H7220_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, Select Care Drugs																								
H7220	011	0	1	02	01	H7220_011_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																								
H7220	012	0	1	01	01	H7220_012_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, Select Care Drugs																								
H7220	012	0	1	01	01	H7220_012_0	5			Generic	4	01	1	2	2	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	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																								
H7220	012	0	1	01	01	H7220_012_0	5			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																			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
H7220	012	0	1	01	01	H7220_012_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.05	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		35.00
H7220	012	0	1	01	01	H7220_012_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																								
H7220	012	0	1	01	01	H7220_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7239	001	0	1	01	01	H7239_001_0	3			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																								
H7239	001	0	1	01	01	H7239_001_0	3			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
H7239	001	0	1	01	01	H7239_001_0	3			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																					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	105.00						105.00				35.00		35.00
H7239	001	0	1	01	01	H7239_001_0	3			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																								
H7239	001	0	1	01	01	H7239_001_0	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				134.02	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7239	001	0	1	01	01	H7239_001_0	3			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																								
H7239	002	0	1	01	01	H7239_002_0	5		N	Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				0.88	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7239	002	0	1	01	01	H7239_002_0	5		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				8.36	23	23	23																				23															23			23								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
H7239	002	0	1	01	01	H7239_002_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				116.59	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
H7239	002	0	1	01	01	H7239_002_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				67.11	40	40	40																				40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7239	002	0	1	01	01	H7239_002_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				181.25	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7239	002	0	1	01	01	H7239_002_0	5		N	Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				0.80	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7239	003	0	1	01	01	H7239_003_0	5			Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				0.88	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7239	003	0	1	01	01	H7239_003_0	5			Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				5.89	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						105.00				35.00		35.00
H7239	003	0	1	01	01	H7239_003_0	5			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				115.82	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
H7239	003	0	1	01	01	H7239_003_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				49.04	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7239	003	0	1	01	01	H7239_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				144.81	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7239	003	0	1	01	01	H7239_003_0	5			Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				1.01	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7284	001	0	1	04	01	H7284_001_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
H7284	001	0	1	04	01	H7284_001_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
H7284	001	0	1	04	01	H7284_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		95.00	35.00		35.00
H7284	001	0	1	04	01	H7284_001_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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
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	008	0	1	04	01	H7284_008_0	3			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
H7284	008	0	1	04	01	H7284_008_0	3			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
H7284	008	0	1	04	01	H7284_008_0	3			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		95.00	35.00		35.00
H7284	008	0	1	04	01	H7284_008_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				79.00	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
H7284	008	0	1	04	01	H7284_008_0	3			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
H7284	009	0	1	04	01	H7284_009_0	3			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
H7284	009	0	1	04	01	H7284_009_0	3			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
H7284	009	0	1	04	01	H7284_009_0	3			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		95.00	35.00		35.00
H7284	009	0	1	04	01	H7284_009_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	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		35.00
H7284	009	0	1	04	01	H7284_009_0	3			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
H7301	002	0	1	04	01	H7301_002_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	002	0	1	04	01	H7301_002_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7301	002	0	1	04	01	H7301_002_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.09	25	25	25				96.39	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	002	0	1	04	01	H7301_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.75	35	35	35				37.45	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
H7301	002	0	1	04	01	H7301_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											957.02	33						1069.33	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
H7301	006	0	1	04	01	H7301_006_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	006	0	1	04	01	H7301_006_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	006	0	1	04	01	H7301_006_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.95	24	24	24				111.77	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
H7301	006	0	1	04	01	H7301_006_0	3			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	25	25	25				39.66	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
H7301	006	0	1	04	01	H7301_006_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.87	25						746.22	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
H7301	007	0	1	04	01	H7301_007_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	007	0	1	04	01	H7301_007_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	007	0	1	04	01	H7301_007_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.43	24	24	24				110.27	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
H7301	007	0	1	04	01	H7301_007_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											40.31	25	25	25				35.62	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	007	0	1	04	01	H7301_007_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											949.74	25						899.25	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
H7301	009	0	1	04	01	H7301_009_0	4			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	009	0	1	04	01	H7301_009_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	009	0	1	04	01	H7301_009_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.87	24	24	24				101.98	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
H7301	009	0	1	04	01	H7301_009_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											37.10	25	25	25				40.04	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
H7301	009	0	1	04	01	H7301_009_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											832.40	25						871.01	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
H7301	013	0	1	04	01	H7301_013_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	013	0	1	04	01	H7301_013_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	013	0	1	04	01	H7301_013_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.59	24	24	24				101.10	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
H7301	013	0	1	04	01	H7301_013_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.26	25	25	25				33.86	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	013	0	1	04	01	H7301_013_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											750.29	25						718.79	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
H7301	015	0	1	04	01	H7301_015_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	015	0	1	04	01	H7301_015_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	015	0	1	04	01	H7301_015_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.86	24	24	24				101.73	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
H7301	015	0	1	04	01	H7301_015_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.62	25	25	25				32.56	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
H7301	015	0	1	04	01	H7301_015_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											772.67	25						732.28	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
H7301	021	0	1	04	01	H7301_021_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	021	0	1	04	01	H7301_021_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	021	0	1	04	01	H7301_021_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.99	24	24	24				101.31	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
H7301	021	0	1	04	01	H7301_021_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.06	25	25	25				33.42	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	021	0	1	04	01	H7301_021_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											757.14	25						722.33	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
H7301	022	0	1	04	01	H7301_022_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	022	0	1	04	01	H7301_022_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	022	0	1	04	01	H7301_022_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											30.02	22	22	22				36.56	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	022	0	1	04	01	H7301_022_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.76	25	25	25				48.29	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	022	0	1	04	01	H7301_022_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											334.74	25						308.74	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
H7301	027	0	1	04	01	H7301_027_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	027	0	1	04	01	H7301_027_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	027	0	1	04	01	H7301_027_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.26	22	22	22				38.52	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	027	0	1	04	01	H7301_027_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.59	25	25	25				42.70	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	027	0	1	04	01	H7301_027_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											331.32	25						292.34	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
H7301	030	0	1	04	01	H7301_030_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	030	0	1	04	01	H7301_030_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H7301	030	0	1	04	01	H7301_030_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.90	22	22	22				38.83	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	030	0	1	04	01	H7301_030_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.00	25	25	25				41.73	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	030	0	1	04	01	H7301_030_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											330.58	25						288.50	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
H7323	005	0	1	04	01	H7323_005_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								19.00	38.00	57.00					12.00	24.00	36.00											19.00	38.00	57.00				12.00	24.00	0.00				19.00				19.00			0.63	0.4		0.63	0.4	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7323	005	0	1	04	01	H7323_005_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7323	005	0	1	04	01	H7323_005_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											123.45	21	21	21				123.45	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
H7323	005	0	1	04	01	H7323_005_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											36.95	36	36	36				36.95	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
H7323	005	0	1	04	01	H7323_005_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, Select Care Drugs																								
H7323	005	0	1	04	01	H7323_005_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	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7323	006	0	1	04	01	H7323_006_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	006	0	1	04	01	H7323_006_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.69	25	25	25				159.69	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
H7323	006	0	1	04	01	H7323_006_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											62.44	39	39	39				60.84	38	38	38										39	39	39				38	38	38			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
H7323	006	0	1	04	01	H7323_006_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, Select Care Drugs																								
H7323	006	0	1	04	01	H7323_006_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	007	0	1	04	01	H7323_007_0	5			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	5			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	007	0	1	04	01	H7323_007_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.25	25	25	25				158.25	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
H7323	007	0	1	04	01	H7323_007_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											77.07	40	40	40				75.14	39	39	39										40	40	40				39	39	39			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
H7323	007	0	1	04	01	H7323_007_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, Select Care Drugs																								
H7323	007	0	1	04	01	H7323_007_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																								
H7323	011	0	1	04	01	H7323_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			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	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	011	0	1	04	01	H7323_011_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											154.70	25	25	25				154.70	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
H7323	011	0	1	04	01	H7323_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											59.08	50	50	50				59.08	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
H7323	011	0	1	04	01	H7323_011_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, Select Care Drugs																								
H7323	011	0	1	04	01	H7323_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																								
H7323	012	0	1	04	01	H7323_012_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	012	0	1	04	01	H7323_012_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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	012	0	1	04	01	H7323_012_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											152.22	25	25	25				152.22	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
H7323	012	0	1	04	01	H7323_012_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											54.74	50	50	50				54.74	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
H7323	012	0	1	04	01	H7323_012_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, Select Care Drugs																								
H7323	012	0	1	04	01	H7323_012_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																								
H7326	001	0	1	04	01	H7326_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																								
H7326	001	0	1	04	01	H7326_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H7326	001	0	1	04	01	H7326_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											159.72	25	25	25				159.72	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
H7326	001	0	1	04	01	H7326_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											46.96	43	43	43				46.96	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
H7326	001	0	1	04	01	H7326_001_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, Select Care Drugs																								
H7326	001	0	1	04	01	H7326_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																								
H7326	003	0	1	04	01	H7326_003_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																								
H7326	003	0	1	04	01	H7326_003_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H7326	003	0	1	04	01	H7326_003_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											162.07	25	25	25				162.07	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
H7326	003	0	1	04	01	H7326_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											50.42	33	33	33				48.90	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	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, Select Care Drugs																								
H7326	003	0	1	04	01	H7326_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																								
H7326	007	0	1	04	01	H7326_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					10.00	20.00	30.00											19.00	38.00	57.00				10.00	20.00	0.00				19.00				19.00			0.63	0.33		0.63	0.33	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7326	007	0	1	04	01	H7326_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7326	007	0	1	04	01	H7326_007_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											126.02	20	20	20				126.02	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
H7326	007	0	1	04	01	H7326_007_0	6			Non-Preferred Drug	3	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	200.00				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
H7326	007	0	1	04	01	H7326_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																								
H7326	007	0	1	04	01	H7326_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																								
H7330	001	0	1	01	01	H7330_001_0	3			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	3			Generic	4	11	3	2	2	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				1.00		0.03			0.00			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7330	001	0	1	01	01	H7330_001_0	3			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																			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										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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				111.69	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	70.00				35.00		35.00
H7330	001	0	1	01	01	H7330_001_0	3			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				674.42	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00						0.00						0.00		0.00
H7355	001	0	1	04	01	H7355_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
H7355	001	0	1	04	01	H7355_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	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
H7355	001	0	1	04	01	H7355_001_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				53.00	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
H7355	001	0	1	04	01	H7355_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				42.00	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
H7355	001	0	1	04	01	H7355_001_0	8			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
H7355	002	0	1	04	01	H7355_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7355	002	0	1	04	01	H7355_002_0	7			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
H7355	002	0	1	04	01	H7355_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				53.00	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
H7355	002	0	1	04	01	H7355_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				43.00	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
H7355	002	0	1	04	01	H7355_002_0	7			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
H7379	001	0	1	04	01	H7379_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7379	001	0	1	04	01	H7379_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	10.00	10.00																			10.00	10.00	10.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										10.00	10.00	10.00				10.00	10.00	10.00				10.00		10.00
H7379	001	0	1	04	01	H7379_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																			47.00	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	70.00	105.00				35.00	35.00	35.00				35.00		35.00
H7379	001	0	1	04	01	H7379_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				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	105.00				35.00		35.00
H7379	001	0	1	04	01	H7379_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				200.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H7379	002	0	1	04	01	H7379_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7379	002	0	1	04	01	H7379_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	10.00	10.00																			10.00	10.00	10.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										10.00	10.00	10.00				10.00	10.00	10.00				10.00		10.00
H7379	002	0	1	04	01	H7379_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																			47.00	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	70.00	105.00				35.00	35.00	35.00				35.00		35.00
H7379	002	0	1	04	01	H7379_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				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	105.00				35.00		35.00
H7379	002	0	1	04	01	H7379_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				200.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H7389	001	0	1	01	01	H7389_001_0	4			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
H7389	001	0	1	01	01	H7389_001_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											767.59	33						642.58	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
H7389	002	0	1	01	01	H7389_002_0	4			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
H7389	002	0	1	01	01	H7389_002_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	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	002	0	1	01	01	H7389_002_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											716.98	33						674.00	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
H7389	003	0	1	01	01	H7389_003_0	4			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
H7389	003	0	1	01	01	H7389_003_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											884.23	33						644.31	33												33						33					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	4			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
H7389	008	0	1	01	01	H7389_008_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	008	0	1	01	01	H7389_008_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											758.29	33						622.92	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
H7389	011	0	1	01	01	H7389_011_0	4			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
H7389	011	0	1	01	01	H7389_011_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	011	0	1	01	01	H7389_011_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											852.03	33						752.95	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
H7397	001	0	1	04	01	H7397_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7397	001	0	1	04	01	H7397_001_0	7			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
H7397	001	0	1	04	01	H7397_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				55.00	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
H7397	001	0	1	04	01	H7397_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				44.00	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
H7397	001	0	1	04	01	H7397_001_0	7			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
H7397	002	0	1	04	01	H7397_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7397	002	0	1	04	01	H7397_002_0	7			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
H7397	002	0	1	04	01	H7397_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				55.00	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
H7397	002	0	1	04	01	H7397_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				44.00	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
H7397	002	0	1	04	01	H7397_002_0	7			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
H7419	001	0	1	48	05	H7419_001_0	4			$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	4			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	4			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	4			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															
H7471	001	0	1	04	01	H7471_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7471	001	0	1	04	01	H7471_001_0	7			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
H7471	001	0	1	04	01	H7471_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H7471	001	0	1	04	01	H7471_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				46.00	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
H7471	001	0	1	04	01	H7471_001_0	7			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
H7471	002	0	1	04	01	H7471_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7471	002	0	1	04	01	H7471_002_0	7			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
H7471	002	0	1	04	01	H7471_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				58.00	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
H7471	002	0	1	04	01	H7471_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				46.00	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
H7471	002	0	1	04	01	H7471_002_0	7			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
H7471	004	0	1	04	01	H7471_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
H7471	004	0	1	04	01	H7471_004_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																			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
H7471	004	0	1	04	01	H7471_004_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.00	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
H7471	004	0	1	04	01	H7471_004_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				52.00	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
H7471	004	0	1	04	01	H7471_004_0	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
H7471	005	0	1	04	01	H7471_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7471	005	0	1	04	01	H7471_005_0	7			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
H7471	005	0	1	04	01	H7471_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H7471	005	0	1	04	01	H7471_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				46.00	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
H7471	005	0	1	04	01	H7471_005_0	7			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
H7471	006	0	1	04	01	H7471_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7471	006	0	1	04	01	H7471_006_0	7			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
H7471	006	0	1	04	01	H7471_006_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H7471	006	0	1	04	01	H7471_006_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				46.00	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
H7471	006	0	1	04	01	H7471_006_0	7			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
H7471	007	0	1	04	01	H7471_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7471	007	0	1	04	01	H7471_007_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																			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
H7471	007	0	1	04	01	H7471_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				52.00	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
H7471	007	0	1	04	01	H7471_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				52.00	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
H7471	007	0	1	04	01	H7471_007_0	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
H7471	008	0	1	04	01	H7471_008_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7471	008	0	1	04	01	H7471_008_0	7			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
H7471	008	0	1	04	01	H7471_008_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H7471	008	0	1	04	01	H7471_008_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				46.00	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
H7471	008	0	1	04	01	H7471_008_0	7			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
H7471	009	0	1	04	01	H7471_009_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7471	009	0	1	04	01	H7471_009_0	7			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
H7471	009	0	1	04	01	H7471_009_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H7471	009	0	1	04	01	H7471_009_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				46.00	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
H7471	009	0	1	04	01	H7471_009_0	7			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
H7511	002	0	1	01	01	H7511_002_0	5			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	5			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										10.00	20.00	30.00										10.00		10.00
H7511	002	0	1	01	01	H7511_002_0	5			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	5			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	5			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31				587.21	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	5			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	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																								
H7518	001	0	1	04	01	H7518_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																								
H7518	001	0	1	04	01	H7518_001_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											153.32	25	25	25				153.32	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
H7518	001	0	1	04	01	H7518_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											51.32	50	50	50				51.32	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
H7518	001	0	1	04	01	H7518_001_0	7			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																								
H7518	001	0	1	04	01	H7518_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																								
H7518	003	0	1	04	01	H7518_003_0	7		N	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					10.00	20.00	30.00											19.00	38.00	57.00				10.00	20.00	0.00				19.00				19.00			0.63	0.33		0.63	0.33	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7518	003	0	1	04	01	H7518_003_0	7		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7518	003	0	1	04	01	H7518_003_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											107.06	19	19	19				107.06	19	19	19										19	19	19				19	19	19			19			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	70.00	105.00	35.00		35.00
H7518	003	0	1	04	01	H7518_003_0	7		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											35.33	36	36	36				35.33	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
H7518	003	0	1	04	01	H7518_003_0	7		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, Select Care Drugs																								
H7518	003	0	1	04	01	H7518_003_0	7		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	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	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										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	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										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	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
H7524	001	0	1	01	01	H7524_001_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				84.00	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		35.00
H7524	001	0	1	01	01	H7524_001_0	5		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	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										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	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										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	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
H7524	002	0	1	01	01	H7524_002_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				89.00	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		35.00
H7524	002	0	1	01	01	H7524_002_0	5		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	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										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	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										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	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
H7524	003	0	1	01	01	H7524_003_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				85.00	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		35.00
H7524	003	0	1	01	01	H7524_003_0	5		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	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										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	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										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	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
H7524	004	0	1	01	01	H7524_004_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				90.00	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		35.00
H7524	004	0	1	01	01	H7524_004_0	5		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
H7605	001	0	1	01	01	H7605_001_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										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	7			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
H7605	001	0	1	01	01	H7605_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H7605	001	0	1	01	01	H7605_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				41.00	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
H7605	001	0	1	01	01	H7605_001_0	7			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
H7605	002	0	1	01	01	H7605_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										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	7			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
H7605	002	0	1	01	01	H7605_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				81.00	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
H7605	002	0	1	01	01	H7605_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				41.00	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
H7605	002	0	1	01	01	H7605_002_0	7			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
H7605	004	0	1	01	01	H7605_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				75.00	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
H7605	004	0	1	01	01	H7605_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				37.00	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
H7605	004	0	1	01	01	H7605_004_0	7			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
H7605	005	0	1	01	01	H7605_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				76.00	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
H7605	005	0	1	01	01	H7605_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				40.00	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
H7605	005	0	1	01	01	H7605_005_0	7			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
H7605	007	0	1	01	01	H7605_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	Preferred Generic, 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	7			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
H7605	007	0	1	01	01	H7605_007_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.00	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
H7605	007	0	1	01	01	H7605_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				37.00	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
H7605	007	0	1	01	01	H7605_007_0	7			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
H7605	008	0	1	01	01	H7605_008_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										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	7			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
H7605	008	0	1	01	01	H7605_008_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				74.00	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
H7605	008	0	1	01	01	H7605_008_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				39.00	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
H7605	008	0	1	01	01	H7605_008_0	7			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
H7605	009	0	1	01	01	H7605_009_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.00	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
H7605	009	0	1	01	01	H7605_009_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				37.00	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
H7605	009	0	1	01	01	H7605_009_0	7			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
H7605	010	0	1	01	01	H7605_010_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.00	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
H7605	010	0	1	01	01	H7605_010_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				37.00	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
H7605	010	0	1	01	01	H7605_010_0	7			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
H7607	002	1	1	01	01	H7607_002_1	11			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	1	1	01	01	H7607_002_1	11			Generic	4	01	1	2	2	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 Brand, Specialty Tier, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7607	002	1	1	01	01	H7607_002_1	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		1.57			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
H7607	002	1	1	01	01	H7607_002_1	11			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	002	1	1	01	01	H7607_002_1	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				812.64	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	002	1	1	01	01	H7607_002_1	11			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	2	1	01	01	H7607_002_2	11			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	2	1	01	01	H7607_002_2	11			Generic	4	01	1	2	2	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 Brand, Specialty Tier, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7607	002	2	1	01	01	H7607_002_2	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		1.57			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
H7607	002	2	1	01	01	H7607_002_2	11			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	002	2	1	01	01	H7607_002_2	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				812.64	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	002	2	1	01	01	H7607_002_2	11			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	3	1	01	01	H7607_002_3	11			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	3	1	01	01	H7607_002_3	11			Generic	4	01	1	2	2	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 Brand, Specialty Tier, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7607	002	3	1	01	01	H7607_002_3	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		1.57			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
H7607	002	3	1	01	01	H7607_002_3	11			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	002	3	1	01	01	H7607_002_3	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				812.64	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	002	3	1	01	01	H7607_002_3	11			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	4	1	01	01	H7607_002_4	11			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	4	1	01	01	H7607_002_4	11			Generic	4	01	1	2	2	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 Brand, Specialty Tier, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7607	002	4	1	01	01	H7607_002_4	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		1.57			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
H7607	002	4	1	01	01	H7607_002_4	11			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	002	4	1	01	01	H7607_002_4	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				812.64	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	002	4	1	01	01	H7607_002_4	11			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	5	1	01	01	H7607_002_5	11			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	002	5	1	01	01	H7607_002_5	11			Generic	4	01	1	2	2	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 Brand, Specialty Tier, Select Care Drugs										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7607	002	5	1	01	01	H7607_002_5	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		1.57			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
H7607	002	5	1	01	01	H7607_002_5	11			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	002	5	1	01	01	H7607_002_5	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				812.64	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	002	5	1	01	01	H7607_002_5	11			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	1	1	01	01	H7607_008_1	10			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	1	1	01	01	H7607_008_1	10			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H7607	008	1	1	01	01	H7607_008_1	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		1.57			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
H7607	008	1	1	01	01	H7607_008_1	10			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	008	1	1	01	01	H7607_008_1	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				914.16	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	008	1	1	01	01	H7607_008_1	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	2	1	01	01	H7607_008_2	10			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	2	1	01	01	H7607_008_2	10			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H7607	008	2	1	01	01	H7607_008_2	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		1.57			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
H7607	008	2	1	01	01	H7607_008_2	10			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	008	2	1	01	01	H7607_008_2	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				914.16	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	008	2	1	01	01	H7607_008_2	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	3	1	01	01	H7607_008_3	10			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	3	1	01	01	H7607_008_3	10			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H7607	008	3	1	01	01	H7607_008_3	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		1.57			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
H7607	008	3	1	01	01	H7607_008_3	10			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	008	3	1	01	01	H7607_008_3	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				914.16	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	008	3	1	01	01	H7607_008_3	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	4	1	01	01	H7607_008_4	10			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	4	1	01	01	H7607_008_4	10			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H7607	008	4	1	01	01	H7607_008_4	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		1.57			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
H7607	008	4	1	01	01	H7607_008_4	10			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	008	4	1	01	01	H7607_008_4	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				914.16	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	008	4	1	01	01	H7607_008_4	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	5	1	01	01	H7607_008_5	10			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 Brand, Specialty Tier, Select Care Drugs																								
H7607	008	5	1	01	01	H7607_008_5	10			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	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										5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H7607	008	5	1	01	01	H7607_008_5	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		1.57			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
H7607	008	5	1	01	01	H7607_008_5	10			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	198.00																99.00				99.00		3.30			3.30			3.19	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
H7607	008	5	1	01	01	H7607_008_5	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				914.16	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	008	5	1	01	01	H7607_008_5	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	011	1	1	01	01	H7607_011_1	10			Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				0.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	1	1	01	01	H7607_011_1	10			Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				15.86	25	25	25																		25	25	25															25			25								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
H7607	011	1	1	01	01	H7607_011_1	10			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				136.09	25	25	25																		25	25	25															25			25								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
H7607	011	1	1	01	01	H7607_011_1	10			Non-Preferred Brand	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.26	25	25	25																		25	25	25															25			25								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
H7607	011	1	1	01	01	H7607_011_1	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				630.04	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	1	1	01	01	H7607_011_1	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	011	2	1	01	01	H7607_011_2	10			Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				0.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	2	1	01	01	H7607_011_2	10			Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				15.86	25	25	25																		25	25	25															25			25								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
H7607	011	2	1	01	01	H7607_011_2	10			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				136.09	25	25	25																		25	25	25															25			25								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
H7607	011	2	1	01	01	H7607_011_2	10			Non-Preferred Brand	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.26	25	25	25																		25	25	25															25			25								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
H7607	011	2	1	01	01	H7607_011_2	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				630.04	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	2	1	01	01	H7607_011_2	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	011	3	1	01	01	H7607_011_3	10			Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				0.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	3	1	01	01	H7607_011_3	10			Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				15.86	25	25	25																		25	25	25															25			25								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
H7607	011	3	1	01	01	H7607_011_3	10			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				136.09	25	25	25																		25	25	25															25			25								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
H7607	011	3	1	01	01	H7607_011_3	10			Non-Preferred Brand	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.26	25	25	25																		25	25	25															25			25								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
H7607	011	3	1	01	01	H7607_011_3	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				630.04	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	3	1	01	01	H7607_011_3	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	011	4	1	01	01	H7607_011_4	10			Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				0.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	4	1	01	01	H7607_011_4	10			Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				15.86	25	25	25																		25	25	25															25			25								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
H7607	011	4	1	01	01	H7607_011_4	10			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				136.09	25	25	25																		25	25	25															25			25								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
H7607	011	4	1	01	01	H7607_011_4	10			Non-Preferred Brand	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.26	25	25	25																		25	25	25															25			25								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
H7607	011	4	1	01	01	H7607_011_4	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				630.04	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	4	1	01	01	H7607_011_4	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7607	011	5	1	01	01	H7607_011_5	10			Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				0.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	5	1	01	01	H7607_011_5	10			Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				15.86	25	25	25																		25	25	25															25			25								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
H7607	011	5	1	01	01	H7607_011_5	10			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				136.09	25	25	25																		25	25	25															25			25								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
H7607	011	5	1	01	01	H7607_011_5	10			Non-Preferred Brand	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				80.26	25	25	25																		25	25	25															25			25								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
H7607	011	5	1	01	01	H7607_011_5	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				630.04	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																								
H7607	011	5	1	01	01	H7607_011_5	10			Select Care Drugs	4	01	2	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 Brand, Specialty Tier, Select Care Drugs																								
H7646	001	0	1	02	01	H7646_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
H7646	001	0	1	02	01	H7646_001_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					10.00	20.00	30.00					10.00	20.00	0.00																20.00				20.00			0.67	0.33	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	10.00	20.00	0.00				20.00		20.00
H7646	001	0	1	02	01	H7646_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					45.00	90.00	135.00					45.00	90.00	135.00																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	105.00				35.00		35.00
H7646	001	0	1	02	01	H7646_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	285.00																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
H7646	001	0	1	02	01	H7646_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
H7646	002	0	1	02	01	H7646_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								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	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					10.00	20.00	0.00																20.00				20.00			0.67	0.33	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	10.00	20.00	0.00				20.00		20.00
H7646	002	0	1	02	01	H7646_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					45.00	90.00	135.00					45.00	90.00	135.00																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	105.00				35.00		35.00
H7646	002	0	1	02	01	H7646_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					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										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	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
H7646	004	0	1	02	01	H7646_004_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
H7646	004	0	1	02	01	H7646_004_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					10.00	20.00	30.00					10.00	20.00	0.00																20.00				20.00			0.67	0.33	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	10.00	20.00	0.00				20.00		20.00
H7646	004	0	1	02	01	H7646_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					45.00	90.00	135.00																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	105.00				35.00		35.00
H7646	004	0	1	02	01	H7646_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					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										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	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
H7646	005	0	1	02	01	H7646_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								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	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					10.00	20.00	0.00																20.00				20.00			0.67	0.33	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	10.00	20.00	0.00				20.00		20.00
H7646	005	0	1	02	01	H7646_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					45.00	90.00	135.00					45.00	90.00	135.00																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	105.00				35.00		35.00
H7646	005	0	1	02	01	H7646_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					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										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	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
H7670	001	0	1	01	01	H7670_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																								
H7670	001	0	1	01	01	H7670_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																								
H7670	001	0	1	01	01	H7670_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	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	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				88.64	50	50	50																		50	50	50															50			50								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			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				519.64	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7670	002	0	1	01	01	H7670_002_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																								
H7670	002	0	1	01	01	H7670_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																								
H7670	002	0	1	01	01	H7670_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	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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				91.16	45	45	45																		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		35.00
H7670	002	0	1	01	01	H7670_002_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				448.09	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H7678	001	0	1	01	01	H7678_001_0	10		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				2	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 Drug, Specialty Tier, Select Care Drugs																								
H7678	001	0	1	01	01	H7678_001_0	10		N	Generic	4	01	1	1	2	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31				3.13	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7678	001	0	1	01	01	H7678_001_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31				49.76	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	94.00				35.00		35.00
H7678	001	0	1	01	01	H7678_001_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31				68.14	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	94.00				35.00		35.00
H7678	001	0	1	01	01	H7678_001_0	10		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				713.98	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
H7678	001	0	1	01	01	H7678_001_0	10		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	100				2	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 Drug, Specialty Tier, Select Care Drugs																								
H7680	001	0	1	01	01	H7680_001_0	3			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	3			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	3			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00						105.00				35.00		35.00
H7680	001	0	1	01	01	H7680_001_0	3			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	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				162.48	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	001	0	1	01	01	H7680_001_0	3			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	4			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	4			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	4			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00						105.00				35.00		35.00
H7680	002	0	1	01	01	H7680_002_0	4			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	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				105.81	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	002	0	1	01	01	H7680_002_0	4			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	007	0	1	01	01	H7680_007_0	4		N	Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				0.93	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	4		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				7.23	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						105.00				35.00		35.00
H7680	007	0	1	01	01	H7680_007_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				124.15	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	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				70.53	40	40	40																				40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7680	007	0	1	01	01	H7680_007_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				173.61	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	007	0	1	01	01	H7680_007_0	4		N	Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				0.93	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	3			Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.04	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	3			Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				6.10	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						105.00				35.00		35.00
H7680	009	0	1	01	01	H7680_009_0	3			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				124.94	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	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				55.17	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	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				168.09	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	009	0	1	01	01	H7680_009_0	3			Select Care Drugs	4	01	1	1	6	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																								
H7680	011	0	1	01	01	H7680_011_0	3			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	3			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	3			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																					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	105.00						105.00				35.00		35.00
H7680	011	0	1	01	01	H7680_011_0	3			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	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				108.52	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	011	0	1	01	01	H7680_011_0	3			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	3			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	3			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																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										15.00	30.00	45.00						45.00				15.00		15.00
H7680	012	0	1	01	01	H7680_012_0	3			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																					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	105.00						105.00				35.00		35.00
H7680	012	0	1	01	01	H7680_012_0	3			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	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				164.40	28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	012	0	1	01	01	H7680_012_0	3			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	4			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	4			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																					30.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										15.00	30.00	30.00						30.00				15.00		15.00
H7680	014	0	1	01	01	H7680_014_0	4			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																					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	105.00						105.00				35.00		35.00
H7680	014	0	1	01	01	H7680_014_0	4			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	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				142.11	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	014	0	1	01	01	H7680_014_0	4			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	015	0	1	01	01	H7680_015_0	3			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	015	0	1	01	01	H7680_015_0	3			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																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										15.00	30.00	45.00						45.00				15.00		15.00
H7680	015	0	1	01	01	H7680_015_0	3			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00						105.00				35.00		35.00
H7680	015	0	1	01	01	H7680_015_0	3			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	015	0	1	01	01	H7680_015_0	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				112.20	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	015	0	1	01	01	H7680_015_0	3			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	016	0	1	01	01	H7680_016_0	3			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	016	0	1	01	01	H7680_016_0	3			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																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										15.00	30.00	45.00						45.00				15.00		15.00
H7680	016	0	1	01	01	H7680_016_0	3			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				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 Drug, Specialty Tier, Select Care Drugs										35.00	70.00	105.00						105.00				35.00		35.00
H7680	016	0	1	01	01	H7680_016_0	3			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	016	0	1	01	01	H7680_016_0	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				106.31	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	016	0	1	01	01	H7680_016_0	3			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	017	0	1	01	01	H7680_017_0	4		N	Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.12	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7680	017	0	1	01	01	H7680_017_0	4		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				7.82	18	18	18																				18															18			18								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	017	0	1	01	01	H7680_017_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				132.07	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
H7680	017	0	1	01	01	H7680_017_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				98.53	39	39	39																				39															39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7680	017	0	1	01	01	H7680_017_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				215.90	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	017	0	1	01	01	H7680_017_0	4		N	Select Care Drugs	4	01	1	1	6	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																								
H7680	018	0	1	01	01	H7680_018_0	3			Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.06	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7680	018	0	1	01	01	H7680_018_0	3			Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				6.29	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	018	0	1	01	01	H7680_018_0	3			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				120.47	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	018	0	1	01	01	H7680_018_0	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				52.69	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7680	018	0	1	01	01	H7680_018_0	3			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				150.25	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	018	0	1	01	01	H7680_018_0	3			Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				1.47	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7680	019	0	1	02	01	H7680_019_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																								
H7680	019	0	1	02	01	H7680_019_0	5			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																					30.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										15.00	30.00	30.00						30.00				15.00		15.00
H7680	019	0	1	02	01	H7680_019_0	5			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																					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	105.00						105.00				35.00		35.00
H7680	019	0	1	02	01	H7680_019_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																								
H7680	019	0	1	02	01	H7680_019_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				166.60	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00												35.00		35.00
H7680	019	0	1	02	01	H7680_019_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																								
H7787	001	0	1	04	01	H7787_001_0	4			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
H7787	001	0	1	04	01	H7787_001_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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
H7787	001	0	1	04	01	H7787_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											753.14	33						671.92	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
H7833	001	0	1	48	05	H7833_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	4.90	0.00	4.90	0.00	4.90	0.00	4.90															
H7833	001	0	1	48	05	H7833_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	12.15	0.00	12.15	0.00	12.15	0.00	12.15															
H7833	001	0	1	48	05	H7833_001_0	2			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	10			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	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	10			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	100				2	2	31	60	100				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	10			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31						2	2	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	4			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
H7849	001	0	1	04	01	H7849_001_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	001	0	1	04	01	H7849_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											688.60	33						600.30	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
H7849	002	0	1	04	01	H7849_002_0	4			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	002	0	1	04	01	H7849_002_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											839.33	33						769.04	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
H7849	006	0	1	04	01	H7849_006_0	4			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
H7849	006	0	1	04	01	H7849_006_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	006	0	1	04	01	H7849_006_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											804.28	33						647.08	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
H7849	015	0	1	04	01	H7849_015_0	4			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	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	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	015	0	1	04	01	H7849_015_0	4			Preferred Brand	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	015	0	1	04	01	H7849_015_0	4			Non-Preferred Drug	4	11	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	015	0	1	04	01	H7849_015_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											801.43	33						680.51	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
H7849	020	0	1	04	01	H7849_020_0	4			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	020	0	1	04	01	H7849_020_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	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	020	0	1	04	01	H7849_020_0	4			Preferred Brand	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	020	0	1	04	01	H7849_020_0	4			Non-Preferred Drug	4	11	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	020	0	1	04	01	H7849_020_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											861.24	33						754.03	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
H7849	024	0	1	04	01	H7849_024_0	4			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	024	0	1	04	01	H7849_024_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											790.57	33						628.79	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
H7849	026	0	1	04	01	H7849_026_0	4			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
H7849	026	0	1	04	01	H7849_026_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	026	0	1	04	01	H7849_026_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											709.22	33						548.89	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	027	0	1	04	01	H7849_027_0	4			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
H7849	027	0	1	04	01	H7849_027_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	027	0	1	04	01	H7849_027_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											662.48	33						447.84	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	029	0	1	04	01	H7849_029_0	4			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	029	0	1	04	01	H7849_029_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											724.11	33						576.06	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
H7849	031	0	1	04	01	H7849_031_0	4			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
H7849	031	0	1	04	01	H7849_031_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	031	0	1	04	01	H7849_031_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											690.03	33						601.22	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
H7849	033	0	1	04	01	H7849_033_0	4			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
H7849	033	0	1	04	01	H7849_033_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	033	0	1	04	01	H7849_033_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											662.66	33						461.84	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	034	0	1	04	01	H7849_034_0	4			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	034	0	1	04	01	H7849_034_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	034	0	1	04	01	H7849_034_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											884.25	33						723.77	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	038	0	1	04	01	H7849_038_0	4			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
H7849	038	0	1	04	01	H7849_038_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	038	0	1	04	01	H7849_038_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											907.46	33						602.65	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
H7849	039	0	1	04	01	H7849_039_0	4			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
H7849	039	0	1	04	01	H7849_039_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	039	0	1	04	01	H7849_039_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											859.47	33						643.00	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
H7849	041	0	1	04	01	H7849_041_0	4			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
H7849	041	0	1	04	01	H7849_041_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	041	0	1	04	01	H7849_041_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											801.19	33						652.95	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
H7849	042	0	1	04	01	H7849_042_0	4			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
H7849	042	0	1	04	01	H7849_042_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	042	0	1	04	01	H7849_042_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											753.58	33						538.92	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	051	0	1	04	01	H7849_051_0	4			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
H7849	051	0	1	04	01	H7849_051_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	051	0	1	04	01	H7849_051_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											664.63	33						696.00	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
H7849	052	0	1	04	01	H7849_052_0	4			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	052	0	1	04	01	H7849_052_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	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	052	0	1	04	01	H7849_052_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	052	0	1	04	01	H7849_052_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											670.17	33						448.32	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
H7849	055	0	1	04	01	H7849_055_0	4			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	055	0	1	04	01	H7849_055_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	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	055	0	1	04	01	H7849_055_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.18	33						713.52	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	059	0	1	04	01	H7849_059_0	4			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	059	0	1	04	01	H7849_059_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											725.02	33						690.41	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	064	1	1	04	01	H7849_064_1	4			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	064	1	1	04	01	H7849_064_1	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	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	064	1	1	04	01	H7849_064_1	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	064	1	1	04	01	H7849_064_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											744.98	33						572.02	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	064	2	1	04	01	H7849_064_2	4			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	064	2	1	04	01	H7849_064_2	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	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	064	2	1	04	01	H7849_064_2	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	064	2	1	04	01	H7849_064_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											744.98	33						572.02	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	064	4	1	04	01	H7849_064_4	4			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	064	4	1	04	01	H7849_064_4	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	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	064	4	1	04	01	H7849_064_4	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	064	4	1	04	01	H7849_064_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											744.98	33						572.02	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	065	0	1	04	01	H7849_065_0	4			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	065	0	1	04	01	H7849_065_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											838.45	33						746.21	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	066	0	1	04	01	H7849_066_0	4			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	066	0	1	04	01	H7849_066_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											671.35	33						647.39	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
H7849	067	0	1	04	01	H7849_067_0	4			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	067	0	1	04	01	H7849_067_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	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	067	0	1	04	01	H7849_067_0	4			Preferred Brand	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	067	0	1	04	01	H7849_067_0	4			Non-Preferred Drug	4	11	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	067	0	1	04	01	H7849_067_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											709.69	33						553.47	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	068	0	1	04	01	H7849_068_0	4			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	068	0	1	04	01	H7849_068_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	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	068	0	1	04	01	H7849_068_0	4			Preferred Brand	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	068	0	1	04	01	H7849_068_0	4			Non-Preferred Drug	4	11	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	068	0	1	04	01	H7849_068_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											733.81	33						560.77	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	070	0	1	04	01	H7849_070_0	4			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
H7849	070	0	1	04	01	H7849_070_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	070	0	1	04	01	H7849_070_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											631.90	33						648.95	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
H7849	077	0	1	04	01	H7849_077_0	4			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	077	0	1	04	01	H7849_077_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											904.23	33						583.73	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	080	0	1	04	01	H7849_080_0	4			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	080	0	1	04	01	H7849_080_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											623.35	33						660.01	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	082	0	1	04	01	H7849_082_0	4			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	082	0	1	04	01	H7849_082_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											733.33	33						582.50	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
H7849	083	0	1	04	01	H7849_083_0	4			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	083	0	1	04	01	H7849_083_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											707.62	33						564.53	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	084	0	1	04	01	H7849_084_0	4			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	084	0	1	04	01	H7849_084_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											677.25	33						581.92	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	085	0	1	04	01	H7849_085_0	4			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	085	0	1	04	01	H7849_085_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											726.29	33						584.65	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
H7849	087	0	1	04	01	H7849_087_0	4			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	087	0	1	04	01	H7849_087_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											586.66	33						418.66	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
H7849	088	0	1	04	01	H7849_088_0	4			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	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	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	088	0	1	04	01	H7849_088_0	4			Preferred Brand	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	088	0	1	04	01	H7849_088_0	4			Non-Preferred Drug	4	11	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	088	0	1	04	01	H7849_088_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											781.33	33						670.52	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	102	1	1	04	01	H7849_102_1	4			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	102	1	1	04	01	H7849_102_1	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	102	1	1	04	01	H7849_102_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											766.29	33						578.97	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
H7849	102	2	1	04	01	H7849_102_2	4			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	102	2	1	04	01	H7849_102_2	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	102	2	1	04	01	H7849_102_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											766.29	33						578.97	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
H7849	102	3	1	04	01	H7849_102_3	4			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	102	3	1	04	01	H7849_102_3	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	102	3	1	04	01	H7849_102_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											766.29	33						578.97	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
H7849	103	0	1	04	01	H7849_103_0	4			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
H7849	103	0	1	04	01	H7849_103_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	103	0	1	04	01	H7849_103_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											738.02	33						606.72	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	104	0	1	04	01	H7849_104_0	4			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
H7849	104	0	1	04	01	H7849_104_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	104	0	1	04	01	H7849_104_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											824.28	33						706.53	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	105	0	1	04	01	H7849_105_0	4			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
H7849	105	0	1	04	01	H7849_105_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	105	0	1	04	01	H7849_105_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											844.97	33						723.77	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	106	0	1	04	01	H7849_106_0	4			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	106	0	1	04	01	H7849_106_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	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	106	0	1	04	01	H7849_106_0	4			Preferred Brand	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	106	0	1	04	01	H7849_106_0	4			Non-Preferred Drug	4	11	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	106	0	1	04	01	H7849_106_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											783.50	33						654.09	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
H7849	107	0	1	04	01	H7849_107_0	4			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	107	0	1	04	01	H7849_107_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	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	107	0	1	04	01	H7849_107_0	4			Preferred Brand	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	107	0	1	04	01	H7849_107_0	4			Non-Preferred Drug	4	11	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	107	0	1	04	01	H7849_107_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											856.65	33						730.75	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	108	0	1	04	01	H7849_108_0	4			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	108	0	1	04	01	H7849_108_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	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	108	0	1	04	01	H7849_108_0	4			Preferred Brand	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	108	0	1	04	01	H7849_108_0	4			Non-Preferred Drug	4	11	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	108	0	1	04	01	H7849_108_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											977.00	33						862.23	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	109	0	1	04	01	H7849_109_0	4			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	109	0	1	04	01	H7849_109_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	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	109	0	1	04	01	H7849_109_0	4			Preferred Brand	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	109	0	1	04	01	H7849_109_0	4			Non-Preferred Drug	4	11	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	109	0	1	04	01	H7849_109_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											923.36	33						767.25	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
H7849	110	0	1	04	01	H7849_110_0	4			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
H7849	110	0	1	04	01	H7849_110_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	110	0	1	04	01	H7849_110_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											645.00	33						593.57	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
H7849	112	1	1	04	01	H7849_112_1	4			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	112	1	1	04	01	H7849_112_1	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	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	112	1	1	04	01	H7849_112_1	4			Preferred Brand	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	112	1	1	04	01	H7849_112_1	4			Non-Preferred Drug	4	11	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	112	1	1	04	01	H7849_112_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.91	33						661.12	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
H7849	112	2	1	04	01	H7849_112_2	4			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	112	2	1	04	01	H7849_112_2	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	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	112	2	1	04	01	H7849_112_2	4			Preferred Brand	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	112	2	1	04	01	H7849_112_2	4			Non-Preferred Drug	4	11	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	112	2	1	04	01	H7849_112_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.91	33						661.12	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
H7849	112	3	1	04	01	H7849_112_3	4			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	112	3	1	04	01	H7849_112_3	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	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	112	3	1	04	01	H7849_112_3	4			Preferred Brand	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	112	3	1	04	01	H7849_112_3	4			Non-Preferred Drug	4	11	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	112	3	1	04	01	H7849_112_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.91	33						661.12	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
H7849	112	4	1	04	01	H7849_112_4	4			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	112	4	1	04	01	H7849_112_4	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	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	112	4	1	04	01	H7849_112_4	4			Preferred Brand	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	112	4	1	04	01	H7849_112_4	4			Non-Preferred Drug	4	11	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	112	4	1	04	01	H7849_112_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											868.91	33						661.12	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
H7849	113	1	1	04	01	H7849_113_1	4			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	113	1	1	04	01	H7849_113_1	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	113	1	1	04	01	H7849_113_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											799.57	33						726.78	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
H7849	113	2	1	04	01	H7849_113_2	4			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	113	2	1	04	01	H7849_113_2	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	113	2	1	04	01	H7849_113_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											799.57	33						726.78	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
H7849	113	3	1	04	01	H7849_113_3	4			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	113	3	1	04	01	H7849_113_3	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	113	3	1	04	01	H7849_113_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											799.57	33						726.78	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
H7849	113	4	1	04	01	H7849_113_4	4			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	113	4	1	04	01	H7849_113_4	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	113	4	1	04	01	H7849_113_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											799.57	33						726.78	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
H7849	114	0	1	04	01	H7849_114_0	4			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	114	0	1	04	01	H7849_114_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	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	114	0	1	04	01	H7849_114_0	4			Preferred Brand	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	114	0	1	04	01	H7849_114_0	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											900.46	33						691.96	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	117	1	1	04	01	H7849_117_1	4			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	117	1	1	04	01	H7849_117_1	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											700.75	33						604.12	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
H7849	117	2	1	04	01	H7849_117_2	4			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	117	2	1	04	01	H7849_117_2	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											700.75	33						604.12	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
H7849	118	0	1	04	01	H7849_118_0	4			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	118	0	1	04	01	H7849_118_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.62	33						644.46	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	119	0	1	04	01	H7849_119_0	4			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	119	0	1	04	01	H7849_119_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.62	33						644.46	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	120	0	1	04	01	H7849_120_0	4			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	120	0	1	04	01	H7849_120_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.62	33						644.46	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	121	0	1	04	01	H7849_121_0	4			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	121	0	1	04	01	H7849_121_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.62	33						644.46	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	123	0	1	04	01	H7849_123_0	4			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
H7849	123	0	1	04	01	H7849_123_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	123	0	1	04	01	H7849_123_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											808.24	33						667.02	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	1	1	04	01	H7849_124_1	4			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
H7849	124	1	1	04	01	H7849_124_1	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	124	1	1	04	01	H7849_124_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											836.64	33						739.51	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
H7849	124	2	1	04	01	H7849_124_2	4			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
H7849	124	2	1	04	01	H7849_124_2	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	124	2	1	04	01	H7849_124_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											836.64	33						739.51	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
H7849	125	0	1	04	01	H7849_125_0	4			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
H7849	125	0	1	04	01	H7849_125_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	125	0	1	04	01	H7849_125_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											808.24	33						667.02	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	127	0	1	04	01	H7849_127_0	4			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	127	0	1	04	01	H7849_127_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											728.35	33						565.41	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	128	0	1	04	01	H7849_128_0	4			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	128	0	1	04	01	H7849_128_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											728.35	33						565.41	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	129	0	1	04	01	H7849_129_0	4			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
H7849	129	0	1	04	01	H7849_129_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	129	0	1	04	01	H7849_129_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											720.80	33						566.31	33												33						33					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	4			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
H7849	130	0	1	04	01	H7849_130_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	130	0	1	04	01	H7849_130_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											720.80	33						566.31	33												33						33					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	131	0	1	04	01	H7849_131_0	4			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
H7849	131	0	1	04	01	H7849_131_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	131	0	1	04	01	H7849_131_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											720.80	33						566.31	33												33						33					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	1	1	04	01	H7849_133_1	4			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	133	1	1	04	01	H7849_133_1	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	133	1	1	04	01	H7849_133_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											864.44	33						670.84	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	133	2	1	04	01	H7849_133_2	4			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	133	2	1	04	01	H7849_133_2	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	133	2	1	04	01	H7849_133_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											864.44	33						670.84	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	133	3	1	04	01	H7849_133_3	4			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	133	3	1	04	01	H7849_133_3	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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	133	3	1	04	01	H7849_133_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											864.44	33						670.84	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	133	4	1	04	01	H7849_133_4	4			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	133	4	1	04	01	H7849_133_4	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	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	4	1	04	01	H7849_133_4	4			Preferred Brand	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	4	1	04	01	H7849_133_4	4			Non-Preferred Drug	4	11	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	133	4	1	04	01	H7849_133_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											864.44	33						670.84	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	134	1	1	04	01	H7849_134_1	4			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
H7849	134	1	1	04	01	H7849_134_1	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	134	1	1	04	01	H7849_134_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											688.46	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
H7849	134	2	1	04	01	H7849_134_2	4			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
H7849	134	2	1	04	01	H7849_134_2	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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	134	2	1	04	01	H7849_134_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											688.46	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
H7849	135	0	1	04	01	H7849_135_0	4			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	135	0	1	04	01	H7849_135_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	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	135	0	1	04	01	H7849_135_0	4			Preferred Brand	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	135	0	1	04	01	H7849_135_0	4			Non-Preferred Drug	4	11	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	135	0	1	04	01	H7849_135_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											744.20	33						626.91	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	136	1	1	04	01	H7849_136_1	4			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	136	1	1	04	01	H7849_136_1	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	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	136	1	1	04	01	H7849_136_1	4			Preferred Brand	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	136	1	1	04	01	H7849_136_1	4			Non-Preferred Drug	4	11	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	136	1	1	04	01	H7849_136_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.63	33						755.09	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
H7849	136	2	1	04	01	H7849_136_2	4			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	136	2	1	04	01	H7849_136_2	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	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	136	2	1	04	01	H7849_136_2	4			Preferred Brand	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	136	2	1	04	01	H7849_136_2	4			Non-Preferred Drug	4	11	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	136	2	1	04	01	H7849_136_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.63	33						755.09	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
H7849	136	3	1	04	01	H7849_136_3	4			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	136	3	1	04	01	H7849_136_3	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	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	136	3	1	04	01	H7849_136_3	4			Preferred Brand	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	136	3	1	04	01	H7849_136_3	4			Non-Preferred Drug	4	11	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	136	3	1	04	01	H7849_136_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.63	33						755.09	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
H7849	137	1	1	04	01	H7849_137_1	4			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	137	1	1	04	01	H7849_137_1	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	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	137	1	1	04	01	H7849_137_1	4			Preferred Brand	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	137	1	1	04	01	H7849_137_1	4			Non-Preferred Drug	4	11	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	137	1	1	04	01	H7849_137_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.52	33						693.16	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	137	2	1	04	01	H7849_137_2	4			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	137	2	1	04	01	H7849_137_2	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	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	137	2	1	04	01	H7849_137_2	4			Preferred Brand	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	137	2	1	04	01	H7849_137_2	4			Non-Preferred Drug	4	11	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	137	2	1	04	01	H7849_137_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.52	33						693.16	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	137	3	1	04	01	H7849_137_3	4			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	137	3	1	04	01	H7849_137_3	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	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	137	3	1	04	01	H7849_137_3	4			Preferred Brand	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	137	3	1	04	01	H7849_137_3	4			Non-Preferred Drug	4	11	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	137	3	1	04	01	H7849_137_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.52	33						693.16	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	137	4	1	04	01	H7849_137_4	4			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	137	4	1	04	01	H7849_137_4	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	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	137	4	1	04	01	H7849_137_4	4			Preferred Brand	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	137	4	1	04	01	H7849_137_4	4			Non-Preferred Drug	4	11	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	137	4	1	04	01	H7849_137_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.52	33						693.16	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	140	1	1	04	01	H7849_140_1	4			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	140	1	1	04	01	H7849_140_1	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	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	140	1	1	04	01	H7849_140_1	4			Preferred Brand	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	140	1	1	04	01	H7849_140_1	4			Non-Preferred Drug	4	11	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	140	1	1	04	01	H7849_140_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											775.96	33						745.99	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	140	2	1	04	01	H7849_140_2	4			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	140	2	1	04	01	H7849_140_2	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	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	140	2	1	04	01	H7849_140_2	4			Preferred Brand	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	140	2	1	04	01	H7849_140_2	4			Non-Preferred Drug	4	11	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	140	2	1	04	01	H7849_140_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											775.96	33						745.99	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
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			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	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.22	50	50	50				42.68	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
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			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	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.40	50	50	50				43.19	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
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			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	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											42.09	50	50	50				40.62	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
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	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	012	0	1	04	01	H7917_012_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	012	0	1	04	01	H7917_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								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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											33.62	50	50	50				37.48	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
H7917	012	0	1	04	01	H7917_012_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	013	0	1	04	01	H7917_013_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	013	0	1	04	01	H7917_013_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	013	0	1	04	01	H7917_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								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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.96	50	50	50				44.05	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
H7917	013	0	1	04	01	H7917_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																								
H7917	014	0	1	04	01	H7917_014_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	014	0	1	04	01	H7917_014_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	014	0	1	04	01	H7917_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								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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.82	50	50	50				39.77	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
H7917	014	0	1	04	01	H7917_014_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	015	0	1	04	01	H7917_015_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	015	0	1	04	01	H7917_015_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	015	0	1	04	01	H7917_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								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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											35.72	50	50	50				39.58	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
H7917	015	0	1	04	01	H7917_015_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	030	0	1	04	01	H7917_030_0	6			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	6			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	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	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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											36.50	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										35.00	70.00	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	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																								
H7917	031	0	1	04	01	H7917_031_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	031	0	1	04	01	H7917_031_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	031	0	1	04	01	H7917_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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											34.34	50	50	50				33.31	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
H7917	031	0	1	04	01	H7917_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																								
H7917	032	0	1	04	01	H7917_032_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	032	0	1	04	01	H7917_032_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	032	0	1	04	01	H7917_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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											36.86	50	50	50				36.42	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
H7917	032	0	1	04	01	H7917_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																								
H7917	033	0	1	04	01	H7917_033_0	6			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	6			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	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	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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											31.42	50	50	50				30.40	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
H7917	033	0	1	04	01	H7917_033_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																								
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			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	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.86	50	50	50				36.38	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	105.00	35.00		35.00
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	6			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	6			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	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	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	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.89	50	50	50				47.93	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
H7917	040	0	1	04	01	H7917_040_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																								
H7917	042	0	1	04	01	H7917_042_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	042	0	1	04	01	H7917_042_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	042	0	1	04	01	H7917_042_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	042	0	1	04	01	H7917_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											42.31	50	50	50				41.59	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
H7917	042	0	1	04	01	H7917_042_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	043	0	1	04	01	H7917_043_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	043	0	1	04	01	H7917_043_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	043	0	1	04	01	H7917_043_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	043	0	1	04	01	H7917_043_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											42.31	50	50	50				41.59	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
H7917	043	0	1	04	01	H7917_043_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																								
H7925	002	0	1	01	01	H7925_002_0	5			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	5			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																								
H7925	002	0	1	01	01	H7925_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											156.48	25	25	25				156.48	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
H7925	002	0	1	01	01	H7925_002_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											47.54	42	42	42				46.41	41	41	41										42	42	42				41	41	41			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
H7925	002	0	1	01	01	H7925_002_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, Select Care Drugs																								
H7925	002	0	1	01	01	H7925_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H7980	001	0	1	04	01	H7980_001_0	9			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
H7980	001	0	1	04	01	H7980_001_0	9			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
H7980	001	0	1	04	01	H7980_001_0	9			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
H7980	001	0	1	04	01	H7980_001_0	9			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										35.00		105.00				35.00		105.00				35.00		35.00
H7980	001	0	1	04	01	H7980_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																								
H7993	001	0	1	01	01	H7993_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
H7993	001	0	1	01	01	H7993_001_0	8			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	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				109.00	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	001	0	1	01	01	H7993_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				41.00	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	001	0	1	01	01	H7993_001_0	8			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	002	0	1	01	01	H7993_002_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
H7993	002	0	1	01	01	H7993_002_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																			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
H7993	002	0	1	01	01	H7993_002_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				103.00	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	002	0	1	01	01	H7993_002_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				49.00	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	002	0	1	01	01	H7993_002_0	8			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	003	0	1	01	01	H7993_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				74.00	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	003	0	1	01	01	H7993_003_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				45.00	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	003	0	1	01	01	H7993_003_0	7			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	004	0	1	01	01	H7993_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
H7993	004	0	1	01	01	H7993_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										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	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				68.00	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	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				50.00	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	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
H7993	005	0	1	01	01	H7993_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.00	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	005	0	1	01	01	H7993_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				38.00	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	005	0	1	01	01	H7993_005_0	7			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	006	0	1	01	01	H7993_006_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
H7993	006	0	1	01	01	H7993_006_0	5			Generic	4	11	3	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	2.50																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1.00	2.00	3.00				1.00	2.00	2.50				1.00		1.00
H7993	006	0	1	01	01	H7993_006_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.00	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
H7993	006	0	1	01	01	H7993_006_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				39.00	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	006	0	1	01	01	H7993_006_0	5			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	007	0	1	01	01	H7993_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	Preferred Generic, 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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	007	0	1	01	01	H7993_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				39.00	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	007	0	1	01	01	H7993_007_0	7			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	008	0	1	01	01	H7993_008_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
H7993	008	0	1	01	01	H7993_008_0	5			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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				84.00	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
H7993	008	0	1	01	01	H7993_008_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				42.00	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	008	0	1	01	01	H7993_008_0	5			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	014	0	1	01	01	H7993_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	014	0	1	01	01	H7993_014_0	7			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	014	0	1	01	01	H7993_014_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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	014	0	1	01	01	H7993_014_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				45.00	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	014	0	1	01	01	H7993_014_0	7			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	019	0	1	01	01	H7993_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	019	0	1	01	01	H7993_019_0	7			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	019	0	1	01	01	H7993_019_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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	019	0	1	01	01	H7993_019_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				45.00	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	019	0	1	01	01	H7993_019_0	7			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	021	0	1	01	01	H7993_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	Preferred Generic, 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	021	0	1	01	01	H7993_021_0	7			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
H7993	021	0	1	01	01	H7993_021_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				63.00	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	021	0	1	01	01	H7993_021_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				48.00	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	021	0	1	01	01	H7993_021_0	7			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	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	001	0	1	04	01	H8003_001_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	001	0	1	04	01	H8003_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											75.74	25	25	25				77.51	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		35.00
H8003	001	0	1	04	01	H8003_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											77.84	50	50	50				66.14	40	40	40				40	40	40															50			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		35.00
H8003	001	0	1	04	01	H8003_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, Select Care Drugs										35.00			35.00			35.00						35.00		35.00
H8003	001	0	1	04	01	H8003_001_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	002	0	1	04	01	H8003_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	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	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	002	0	1	04	01	H8003_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											75.74	25	25	25				77.51	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		35.00
H8003	002	0	1	04	01	H8003_002_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											77.84	50	50	50				66.14	40	40	40				40	40	40															50			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		35.00
H8003	002	0	1	04	01	H8003_002_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
H8003	002	0	1	04	01	H8003_002_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	003	0	1	04	01	H8003_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	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	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	003	0	1	04	01	H8003_003_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											77.69	25	25	25				80.30	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		35.00
H8003	003	0	1	04	01	H8003_003_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											77.19	50	50	50				73.03	40	40	40				40	40	40															50			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		35.00
H8003	003	0	1	04	01	H8003_003_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
H8003	003	0	1	04	01	H8003_003_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	004	0	1	04	01	H8003_004_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	004	0	1	04	01	H8003_004_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	004	0	1	04	01	H8003_004_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											101.10	25	25	25				82.29	21	21	21				21	21	21															25			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		35.00
H8003	004	0	1	04	01	H8003_004_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											90.51	42	42	42				78.17	40	40	40				40	40	40															42			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		35.00
H8003	004	0	1	04	01	H8003_004_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, Select Care Drugs										35.00			35.00			35.00						35.00		35.00
H8003	004	0	1	04	01	H8003_004_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			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			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	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											99.85	25	25	25				84.74	21	21	21				21	21	21															25			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		35.00
H8003	005	0	1	04	01	H8003_005_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											65.84	42	42	42				67.08	40	40	40				40	40	40															42			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		35.00
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												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
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	006	0	1	04	01	H8003_006_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	006	0	1	04	01	H8003_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					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	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											110.84	25	25	25				91.13	21	21	21				21	21	21															25			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		35.00
H8003	006	0	1	04	01	H8003_006_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											99.51	42	42	42				80.36	40	40	40				40	40	40															42			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		35.00
H8003	006	0	1	04	01	H8003_006_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, Select Care Drugs										35.00			35.00			35.00						35.00		35.00
H8003	006	0	1	04	01	H8003_006_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																								
H8010	002	0	1	01	01	H8010_002_0	5			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	5			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																					24.00																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	5			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																					135.00																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	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										35.00	70.00	105.00						105.00				35.00		35.00
H8010	002	0	1	01	01	H8010_002_0	5			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	5			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	5			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																					24.00																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	5			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				60.08	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
H8010	003	0	1	01	01	H8010_003_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				71.44	35	35	35																				35															35			35								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	5			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					29	29	29																				29															29			29								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	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	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	10			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	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	001	0	1	04	01	H8014_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								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	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	90	1	2	30	60	90					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																								
H8019	002	0	1	02	01	H8019_002_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	16.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	16.00				13.00		13.00
H8019	002	0	1	02	01	H8019_002_0	6			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											110.47	25	25	25				85.98	20	20	20				20	20	20																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											82.03	50	50	50				53.85	45	45	45				45	45	45																50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												29	31												33							33																								33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																								
H8019	002	0	1	02	01	H8019_002_0	6			Vaccines	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																								
H8026	001	0	1	48	05	H8026_001_0	7			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	7			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	7			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	7			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	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	7			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	100				2	2	31	60	100				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	7			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31						2	2	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	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	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	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																			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				132.57	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
H8064	002	0	1	04	01	H8064_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				68.56	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	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																								
H8070	001	0	1	04	01	H8070_001_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																								
H8070	001	0	1	04	01	H8070_001_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																								
H8070	001	0	1	04	01	H8070_001_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
H8070	001	0	1	04	01	H8070_001_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										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	9			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2000.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8070	002	0	1	04	01	H8070_002_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																								
H8070	002	0	1	04	01	H8070_002_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																								
H8070	002	0	1	04	01	H8070_002_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
H8070	002	0	1	04	01	H8070_002_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										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	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2000.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8095	001	0	1	01	01	H8095_001_0	14			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																								
H8095	001	0	1	01	01	H8095_001_0	14			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	24.00	0.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8095	001	0	1	01	01	H8095_001_0	14			Preferred Brand	4	11	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
H8095	001	0	1	01	01	H8095_001_0	14			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				100.00	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
H8095	001	0	1	01	01	H8095_001_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1598.77	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H8133	001	0	1	01	01	H8133_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8133	001	0	1	01	01	H8133_001_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8133	001	0	1	01	01	H8133_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					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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											68.77	50	50	50				83.53	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
H8133	001	0	1	01	01	H8133_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											561.15	33						663.94	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8133	005	0	1	01	01	H8133_005_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8133	005	0	1	01	01	H8133_005_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8133	005	0	1	01	01	H8133_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	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	005	0	1	01	01	H8133_005_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											99.10	32	32	32				98.53	31	31	31										32	32	32				31	31	31			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
H8133	005	0	1	01	01	H8133_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											402.01	33						545.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8142	001	0	1	02	01	H8142_001_0	11			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										10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H8142	001	0	1	02	01	H8142_001_0	11			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	11			Preferred Brand	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	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					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	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																								
H8142	002	0	1	02	01	H8142_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								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										8.00	16.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00				8.00		8.00
H8142	002	0	1	02	01	H8142_002_0	10			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	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	002	0	1	02	01	H8142_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								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	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																								
H8142	003	0	1	02	01	H8142_003_0	10			Preferred Generic	4	11	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										7.00	14.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
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												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8142	007	0	1	02	01	H8142_007_0	11			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										10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H8142	007	0	1	02	01	H8142_007_0	11			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	11			Preferred Brand	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	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					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	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																								
H8145	004	0	1	09	04	H8145_004_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																									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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H8145	004	0	1	09	04	H8145_004_0	3			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																								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
H8145	004	0	1	09	04	H8145_004_0	3			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	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		95.00	35.00		35.00
H8145	006	0	1	09	04	H8145_006_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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
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	3			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	032	0	1	09	04	H8145_032_0	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H8145	032	0	1	09	04	H8145_032_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				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		35.00
H8145	032	0	1	09	04	H8145_032_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										35.00						35.00			35.00			35.00		35.00
H8145	052	0	1	09	04	H8145_052_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H8145	052	0	1	09	04	H8145_052_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				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		35.00
H8145	052	0	1	09	04	H8145_052_0	3			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	069	0	1	09	04	H8145_069_0	3			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	3			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	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																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	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
H8145	069	0	1	09	04	H8145_069_0	3			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																								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
H8145	069	0	1	09	04	H8145_069_0	3			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	084	0	1	09	04	H8145_084_0	3			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	3			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	3			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		95.00	35.00		35.00
H8145	084	0	1	09	04	H8145_084_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	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		35.00
H8145	084	0	1	09	04	H8145_084_0	3			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	091	0	1	09	04	H8145_091_0	3			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
H8145	091	0	1	09	04	H8145_091_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	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	3			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		95.00	35.00		35.00
H8145	091	0	1	09	04	H8145_091_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	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
H8145	091	0	1	09	04	H8145_091_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										35.00						35.00			35.00			35.00		35.00
H8145	164	1	1	09	04	H8145_164_1	3			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
H8145	164	1	1	09	04	H8145_164_1	3			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	164	1	1	09	04	H8145_164_1	3			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		70.00	35.00		35.00
H8145	164	1	1	09	04	H8145_164_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H8145	164	1	1	09	04	H8145_164_1	3			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	164	2	1	09	04	H8145_164_2	3			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
H8145	164	2	1	09	04	H8145_164_2	3			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	164	2	1	09	04	H8145_164_2	3			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		70.00	35.00		35.00
H8145	164	2	1	09	04	H8145_164_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H8145	164	2	1	09	04	H8145_164_2	3			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
H8166	001	0	1	04	01	H8166_001_0	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											105.05	25		25				108.91	25		25												25						25			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
H8166	001	0	1	04	01	H8166_001_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.62	44		44				38.46	44		44												44						44			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
H8166	001	0	1	04	01	H8166_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8166	002	0	1	04	01	H8166_002_0	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											100.24	25		25				107.20	25		25												25						25			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
H8166	002	0	1	04	01	H8166_002_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.78	50		50				43.32	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
H8166	002	0	1	04	01	H8166_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8166	004	0	1	04	01	H8166_004_0	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											100.21	25		25				107.16	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H8166	004	0	1	04	01	H8166_004_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.73	50		50				43.36	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
H8166	004	0	1	04	01	H8166_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8173	001	0	1	01	01	H8173_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
H8173	001	0	1	01	01	H8173_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																			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	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				106.00	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
H8173	001	0	1	01	01	H8173_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				44.00	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
H8173	001	0	1	01	01	H8173_001_0	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
H8173	002	0	1	01	01	H8173_002_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
H8173	002	0	1	01	01	H8173_002_0	8			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	002	0	1	01	01	H8173_002_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				105.00	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
H8173	002	0	1	01	01	H8173_002_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				55.00	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
H8173	002	0	1	01	01	H8173_002_0	8			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
H8173	007	0	1	01	01	H8173_007_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
H8173	007	0	1	01	01	H8173_007_0	8			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	007	0	1	01	01	H8173_007_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				65.00	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
H8173	007	0	1	01	01	H8173_007_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				40.00	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
H8173	007	0	1	01	01	H8173_007_0	8			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
H8173	011	0	1	01	01	H8173_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										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	7			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
H8173	011	0	1	01	01	H8173_011_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				120.00	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
H8173	011	0	1	01	01	H8173_011_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				37.00	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
H8173	011	0	1	01	01	H8173_011_0	7			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
H8173	013	0	1	01	01	H8173_013_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
H8173	013	0	1	01	01	H8173_013_0	5			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																			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
H8173	013	0	1	01	01	H8173_013_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.00	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
H8173	013	0	1	01	01	H8173_013_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				42.00	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
H8173	013	0	1	01	01	H8173_013_0	5			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
H8173	016	0	1	01	01	H8173_016_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										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	7			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	016	0	1	01	01	H8173_016_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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
H8173	016	0	1	01	01	H8173_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				38.00	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
H8173	016	0	1	01	01	H8173_016_0	7			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
H8173	019	0	1	01	01	H8173_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.00	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
H8173	019	0	1	01	01	H8173_019_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				40.00	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
H8173	019	0	1	01	01	H8173_019_0	7			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
H8173	020	0	1	01	01	H8173_020_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
H8173	020	0	1	01	01	H8173_020_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																			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	020	0	1	01	01	H8173_020_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H8173	020	0	1	01	01	H8173_020_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				45.00	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
H8173	020	0	1	01	01	H8173_020_0	8			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
H8173	021	0	1	01	01	H8173_021_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
H8173	021	0	1	01	01	H8173_021_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																			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	021	0	1	01	01	H8173_021_0	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				53.00	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
H8173	021	0	1	01	01	H8173_021_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				52.00	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
H8173	021	0	1	01	01	H8173_021_0	8			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
H8181	001	0	1	04	01	H8181_001_0	9			Preferred Generic	4	01	3	2	1	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	0.00	0.00	0.00																									2.00	4.00	6.00				2.00	4.00	0.00				0.00				0.00		0.00				0.07	0.07	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				2.00	4.00	6.00	2.00	4.00	0.00	0.00		0.00
H8181	001	0	1	04	01	H8181_001_0	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																									14.00	28.00	42.00				14.00	28.00	0.00				14.00				14.00		0.47				0.47	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00				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	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	131.00				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	95.00	35.00		35.00
H8181	001	0	1	04	01	H8181_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	300.00				100.00	200.00	290.00				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	95.00	35.00		35.00
H8181	001	0	1	04	01	H8181_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				352.07	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8181	002	0	1	04	01	H8181_002_0	9			Preferred Generic	4	01	3	2	1	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	0.00	0.00	0.00																									2.00	4.00	6.00				2.00	4.00	0.00				0.00				0.00		0.00				0.07	0.07	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				2.00	4.00	6.00	2.00	4.00	0.00	0.00		0.00
H8181	002	0	1	04	01	H8181_002_0	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																									14.00	28.00	42.00				14.00	28.00	0.00				14.00				14.00		0.47				0.47	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00				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	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	131.00				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	95.00	35.00		35.00
H8181	002	0	1	04	01	H8181_002_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	200.00	290.00				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	95.00	35.00		35.00
H8181	002	0	1	04	01	H8181_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				348.58	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8181	003	0	1	04	01	H8181_003_0	9			Preferred Generic	4	01	3	2	1	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	0.00	0.00	0.00																									2.00	4.00	6.00				2.00	4.00	0.00				0.00				0.00		0.00				0.07	0.07	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				2.00	4.00	6.00	2.00	4.00	0.00	0.00		0.00
H8181	003	0	1	04	01	H8181_003_0	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																									14.00	28.00	42.00				14.00	28.00	0.00				14.00				14.00		0.47				0.47	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00				14.00	28.00	42.00	14.00	28.00	0.00	14.00		14.00
H8181	003	0	1	04	01	H8181_003_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	131.00				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	95.00	35.00		35.00
H8181	003	0	1	04	01	H8181_003_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	200.00	290.00				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	95.00	35.00		35.00
H8181	003	0	1	04	01	H8181_003_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				335.07	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8197	002	1	1	48	05	H8197_002_1	8			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	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	8			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	100				2	2	31	60	100				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	8			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31						2	2	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	8			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	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	8			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	100				2	2	31	60	100				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	8			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31						2	2	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	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																								
H8211	001	0	1	04	01	H8211_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																								
H8211	001	0	1	04	01	H8211_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
H8211	001	0	1	04	01	H8211_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8211	001	0	1	04	01	H8211_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				179.00	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
H8211	006	0	1	04	01	H8211_006_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																								
H8211	006	0	1	04	01	H8211_006_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																								
H8211	006	0	1	04	01	H8211_006_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
H8211	006	0	1	04	01	H8211_006_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8211	006	0	1	04	01	H8211_006_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				187.00	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
H8211	007	0	1	04	01	H8211_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																								
H8211	007	0	1	04	01	H8211_007_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																								
H8211	007	0	1	04	01	H8211_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
H8211	007	0	1	04	01	H8211_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8211	007	0	1	04	01	H8211_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				157.00	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
H8211	009	0	1	04	01	H8211_009_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																								
H8211	009	0	1	04	01	H8211_009_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																								
H8211	009	0	1	04	01	H8211_009_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
H8211	009	0	1	04	01	H8211_009_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8211	009	0	1	04	01	H8211_009_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				143.00	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
H8211	011	0	1	04	01	H8211_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																								
H8211	011	0	1	04	01	H8211_011_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																								
H8211	011	0	1	04	01	H8211_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
H8211	011	0	1	04	01	H8211_011_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8211	011	0	1	04	01	H8211_011_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				190.00	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
H8211	012	0	1	04	01	H8211_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																								
H8211	012	0	1	04	01	H8211_012_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																								
H8211	012	0	1	04	01	H8211_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
H8211	012	0	1	04	01	H8211_012_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8211	012	0	1	04	01	H8211_012_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
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															
H8320	001	0	1	04	01	H8320_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8320	001	0	1	04	01	H8320_001_0	7			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
H8320	001	0	1	04	01	H8320_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H8320	001	0	1	04	01	H8320_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				44.00	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
H8320	001	0	1	04	01	H8320_001_0	7			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
H8320	002	0	1	04	01	H8320_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8320	002	0	1	04	01	H8320_002_0	7			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
H8320	002	0	1	04	01	H8320_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				57.00	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
H8320	002	0	1	04	01	H8320_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				45.00	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
H8320	002	0	1	04	01	H8320_002_0	7			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
H8320	003	0	1	04	01	H8320_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8320	003	0	1	04	01	H8320_003_0	7			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
H8320	003	0	1	04	01	H8320_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H8320	003	0	1	04	01	H8320_003_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				44.00	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
H8320	003	0	1	04	01	H8320_003_0	7			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
H8320	004	0	1	04	01	H8320_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8320	004	0	1	04	01	H8320_004_0	7			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
H8320	004	0	1	04	01	H8320_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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
H8320	004	0	1	04	01	H8320_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				45.00	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
H8320	004	0	1	04	01	H8320_004_0	7			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
H8320	005	0	1	04	01	H8320_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8320	005	0	1	04	01	H8320_005_0	7			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
H8320	005	0	1	04	01	H8320_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H8320	005	0	1	04	01	H8320_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				44.00	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
H8320	005	0	1	04	01	H8320_005_0	7			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
H8320	006	0	1	04	01	H8320_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8320	006	0	1	04	01	H8320_006_0	7			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
H8320	006	0	1	04	01	H8320_006_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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
H8320	006	0	1	04	01	H8320_006_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				45.00	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
H8320	006	0	1	04	01	H8320_006_0	7			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
H8332	004	0	1	01	01	H8332_004_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H8332	004	0	1	01	01	H8332_004_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H8332	004	0	1	01	01	H8332_004_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.68	22	22	22				45.92	22	22	22										22	22	22				22	22	22				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.59	25	25	25				49.86	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
H8332	004	0	1	01	01	H8332_004_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											334.90	25						304.52	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
H8385	001	0	1	04	01	H8385_001_0	4			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	2	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																								
H8385	001	0	1	04	01	H8385_001_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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	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										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
H8385	001	0	1	04	01	H8385_001_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	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	001	0	1	04	01	H8385_001_0	4			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											78.05	50	50	50				77.48	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
H8385	001	0	1	04	01	H8385_001_0	4			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											678.63	31	31	31				719.66	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8385	001	0	1	04	01	H8385_001_0	4			Select Care Drugs	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	0.00				0.00				0.00			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	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	2	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																								
H8385	002	0	1	04	01	H8385_002_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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	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										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
H8385	002	0	1	04	01	H8385_002_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	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	5			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.40	50	50	50				73.24	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
H8385	002	0	1	04	01	H8385_002_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											585.97	31	31	31				606.11	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8385	002	0	1	04	01	H8385_002_0	5			Select Care Drugs	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	0.00				0.00				0.00			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	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	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	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	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										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
H8385	003	0	1	04	01	H8385_003_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	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	4			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											72.34	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, Select Care Drugs										35.00	70.00	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	4			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											786.96	30	30	30				816.83	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	4			Select Care Drugs	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	0.00				0.00				0.00			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	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	2	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																								
H8385	004	0	1	04	01	H8385_004_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	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	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										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
H8385	004	0	1	04	01	H8385_004_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	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	5			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											71.77	50	50	50				71.29	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
H8385	004	0	1	04	01	H8385_004_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											634.26	31	31	31				663.45	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8385	004	0	1	04	01	H8385_004_0	5			Select Care Drugs	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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8432	009	0	1	02	01	H8432_009_0	8			Preferred Generic	4	11	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																								
H8432	009	0	1	02	01	H8432_009_0	8			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					9.00	27.00	27.00																14.00				14.00			0.47	0.30	0.30			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8432	009	0	1	02	01	H8432_009_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											89.65	20	20	20				89.65	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
H8432	009	0	1	02	01	H8432_009_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											68.76	35	35	35				68.76	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		35.00
H8432	009	0	1	02	01	H8432_009_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																								
H8432	010	0	1	02	01	H8432_010_0	7			Preferred Generic	4	11	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																								
H8432	010	0	1	02	01	H8432_010_0	7			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					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																								
H8432	010	0	1	02	01	H8432_010_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											92.94	20	20	20				92.94	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
H8432	010	0	1	02	01	H8432_010_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											69.74	35	35	35				69.74	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		35.00
H8432	010	0	1	02	01	H8432_010_0	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	011	0	1	02	01	H8432_011_0	8			Preferred Generic	4	11	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																								
H8432	011	0	1	02	01	H8432_011_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																								
H8432	011	0	1	02	01	H8432_011_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											113.19	25	25	25				90.55	20	20	20				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		35.00
H8432	011	0	1	02	01	H8432_011_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											51.57	25	25	25				51.57	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		35.00
H8432	011	0	1	02	01	H8432_011_0	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	016	0	1	02	01	H8432_016_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					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	02	01	H8432_016_0	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					8.00	24.00	24.00																13.00				13.00			0.43	0.27	0.27			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8432	016	0	1	02	01	H8432_016_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.08	20	20	20				75.08	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		35.00
H8432	016	0	1	02	01	H8432_016_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											73.12	35	35	35				73.12	35	35	35				35	35	35															35			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
H8432	016	0	1	02	01	H8432_016_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																								
H8432	016	0	1	02	01	H8432_016_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																								
H8432	040	0	1	01	01	H8432_040_0	8			Preferred Generic	4	11	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																								
H8432	040	0	1	01	01	H8432_040_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																								
H8432	040	0	1	01	01	H8432_040_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											112.53	25	25	25				90.02	20	20	20				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		35.00
H8432	040	0	1	01	01	H8432_040_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											60.59	25	25	25				60.59	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		35.00
H8432	040	0	1	01	01	H8432_040_0	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																								
H8452	001	0	1	48	05	H8452_001_0	4			Generic Drugs	4	11		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															
H8547	001	0	1	01	01	H8547_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8547	001	0	1	01	01	H8547_001_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8547	001	0	1	01	01	H8547_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					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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											72.51	50	50	50				74.98	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
H8547	001	0	1	01	01	H8547_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											702.08	33						642.43	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8552	028	0	1	04	01	H8552_028_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																								
H8552	028	0	1	04	01	H8552_028_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																								
H8552	028	0	1	04	01	H8552_028_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											63.94	25	25	25				51.15	20	20	20				20	20	20															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		35.00
H8552	028	0	1	04	01	H8552_028_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											91.39	25	25	25				91.39	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		35.00
H8552	028	0	1	04	01	H8552_028_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																								
H8552	028	0	1	04	01	H8552_028_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																								
H8552	029	0	1	04	01	H8552_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								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																								
H8552	029	0	1	04	01	H8552_029_0	8			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	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.50	25	25	25				75.50	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		35.00
H8552	029	0	1	04	01	H8552_029_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											47.82	25	25	25				47.82	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		35.00
H8552	029	0	1	04	01	H8552_029_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																								
H8552	029	0	1	04	01	H8552_029_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																								
H8553	001	0	1	04	01	H8553_001_0	5			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																								
H8553	001	0	1	04	01	H8553_001_0	5			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																								
H8553	001	0	1	04	01	H8553_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.56	25	25	25				155.56	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
H8553	001	0	1	04	01	H8553_001_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											68.11	45	45	45				66.59	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
H8553	001	0	1	04	01	H8553_001_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, Select Care Drugs																								
H8553	001	0	1	04	01	H8553_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8554	001	0	1	01	01	H8554_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8554	001	0	1	01	01	H8554_001_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8554	001	0	1	01	01	H8554_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	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.21	50	50	50				80.71	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
H8554	001	0	1	01	01	H8554_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											703.82	33						665.08	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8554	004	0	1	01	01	H8554_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8554	004	0	1	01	01	H8554_004_0	9			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	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8554	004	0	1	01	01	H8554_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	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	004	0	1	01	01	H8554_004_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											112.60	25	25	25				102.29	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
H8554	004	0	1	01	01	H8554_004_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											475.31	25						472.89	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8578	001	0	1	01	01	H8578_001_0	7			Preferred Generic	4	11	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													10.00						0.00				5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8578	001	0	1	01	01	H8578_001_0	7			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								20.00	40.00	60.00					10.00	20.00	30.00													40.00						20.00				20.00				20.00			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			40.00			20.00	20.00		20.00
H8578	001	0	1	01	01	H8578_001_0	7			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													94.00						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	105.00			70.00			70.00	35.00		35.00
H8578	001	0	1	01	01	H8578_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	90	1	2						90	30		31											97.94	38	38	38				95.85	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			70.00			70.00	35.00		35.00
H8578	001	0	1	01	01	H8578_001_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										35.00			35.00									35.00		35.00
H8578	004	0	1	01	01	H8578_004_0	7			Preferred Generic	4	11	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													10.00						0.00				5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8578	004	0	1	01	01	H8578_004_0	7			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								20.00	40.00	60.00					10.00	20.00	30.00													40.00						20.00				20.00				20.00			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			40.00			20.00	20.00		20.00
H8578	004	0	1	01	01	H8578_004_0	7			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													94.00						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	105.00			70.00			70.00	35.00		35.00
H8578	004	0	1	01	01	H8578_004_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	90	1	2						90	30		31											98.09	38	38	38				98.45	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			70.00			70.00	35.00		35.00
H8578	004	0	1	01	01	H8578_004_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										35.00			35.00									35.00		35.00
H8578	012	0	1	01	01	H8578_012_0	11			Preferred Generic	4	11	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													10.00						0.00				5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8578	012	0	1	01	01	H8578_012_0	11			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								20.00	40.00	60.00					10.00	20.00	30.00													40.00						20.00				20.00				20.00			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			40.00			20.00	20.00		20.00
H8578	012	0	1	01	01	H8578_012_0	11			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													94.00						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	105.00			70.00			70.00	35.00		35.00
H8578	012	0	1	01	01	H8578_012_0	11			Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	90	1	2						90	30		31											99.76	36	36	36				94.23	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			70.00			70.00	35.00		35.00
H8578	012	0	1	01	01	H8578_012_0	11			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	27						1.00	27																							27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00									35.00		35.00
H8604	011	0	1	04	01	H8604_011_0	6			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	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	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	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	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	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	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	6			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	7			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																								
H8604	014	1	1	04	01	H8604_014_1	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										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	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.13	20	20	20				51.00	20	20	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	70.00	105.00	35.00		35.00
H8604	014	1	1	04	01	H8604_014_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											33.47	40	40	40				26.69	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
H8604	014	1	1	04	01	H8604_014_1	7			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	7			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																								
H8604	014	2	1	04	01	H8604_014_2	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										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	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.13	20	20	20				51.00	20	20	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	70.00	105.00	35.00		35.00
H8604	014	2	1	04	01	H8604_014_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											33.47	40	40	40				26.69	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
H8604	014	2	1	04	01	H8604_014_2	7			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	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	003	0	1	04	01	H8634_003_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	003	0	1	04	01	H8634_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.94	42	42	42				86.91	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
H8634	003	0	1	04	01	H8634_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											551.40	33						606.04	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	004	0	1	04	01	H8634_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	004	0	1	04	01	H8634_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	004	0	1	04	01	H8634_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	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	8			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				83.01	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
H8634	004	0	1	04	01	H8634_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											650.63	33						560.25	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	008	0	1	04	01	H8634_008_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	008	0	1	04	01	H8634_008_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	008	0	1	04	01	H8634_008_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	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	008	0	1	04	01	H8634_008_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											98.30	41	41	41				98.60	37	37	37										41	41	41				37	37	37			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
H8634	008	0	1	04	01	H8634_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											523.23	30						524.02	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	010	0	1	04	01	H8634_010_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	010	0	1	04	01	H8634_010_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	010	0	1	04	01	H8634_010_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.38	47	47	47				95.59	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
H8634	010	0	1	04	01	H8634_010_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											668.17	30						595.45	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	012	0	1	04	01	H8634_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	012	0	1	04	01	H8634_012_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	012	0	1	04	01	H8634_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											73.79	50	50	50				86.04	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
H8634	012	0	1	04	01	H8634_012_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											676.6	33						495.07	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	016	0	1	04	01	H8634_016_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	016	0	1	04	01	H8634_016_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	016	0	1	04	01	H8634_016_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.77	50	50	50				99.73	42	42	42										50	50	50				42	42	42			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
H8634	016	0	1	04	01	H8634_016_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											600.56	30						412.08	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	017	0	1	04	01	H8634_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	017	0	1	04	01	H8634_017_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	017	0	1	04	01	H8634_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	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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.47	50	50	50				85.03	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
H8634	017	0	1	04	01	H8634_017_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											633.83	33						575.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	018	0	1	04	01	H8634_018_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	018	0	1	04	01	H8634_018_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	018	0	1	04	01	H8634_018_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	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	018	0	1	04	01	H8634_018_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											98.53	25	25	25				81.22	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
H8634	018	0	1	04	01	H8634_018_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											523.90	25						432.58	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	020	0	1	04	01	H8634_020_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	020	0	1	04	01	H8634_020_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	020	0	1	04	01	H8634_020_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	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	020	0	1	04	01	H8634_020_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											107.54	25	25	25				97.15	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
H8634	020	0	1	04	01	H8634_020_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											404.50	25						409.78	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8634	021	0	1	04	01	H8634_021_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H8634	021	0	1	04	01	H8634_021_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H8634	021	0	1	04	01	H8634_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								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	021	0	1	04	01	H8634_021_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											97.84	25	25	25				83.64	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
H8634	021	0	1	04	01	H8634_021_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											476.96	25						547.74	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8649	003	0	1	02	01	H8649_003_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H8649	003	0	1	02	01	H8649_003_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H8649	003	0	1	02	01	H8649_003_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.13	24	24	24				106.86	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
H8649	003	0	1	02	01	H8649_003_0	2			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	25	25	25				34.47	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
H8649	003	0	1	02	01	H8649_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											759.42	25						1050.92	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
H8649	008	0	1	02	01	H8649_008_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H8649	008	0	1	02	01	H8649_008_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H8649	008	0	1	02	01	H8649_008_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.25	24	24	24				102.23	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
H8649	008	0	1	02	01	H8649_008_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.24	25	25	25				34.62	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
H8649	008	0	1	02	01	H8649_008_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											707.53	25						846.81	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
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			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			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			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			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					30																																					30			30								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	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	003	0	1	04	01	H8768_003_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																								
H8768	003	0	1	04	01	H8768_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
H8768	003	0	1	04	01	H8768_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	003	0	1	04	01	H8768_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				183.00	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
H8768	005	0	1	04	01	H8768_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																								
H8768	005	0	1	04	01	H8768_005_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																								
H8768	005	0	1	04	01	H8768_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
H8768	005	0	1	04	01	H8768_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	005	0	1	04	01	H8768_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				198.00	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
H8768	007	0	1	04	01	H8768_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																								
H8768	007	0	1	04	01	H8768_007_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																								
H8768	007	0	1	04	01	H8768_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
H8768	007	0	1	04	01	H8768_007_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	007	0	1	04	01	H8768_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
H8768	008	0	1	04	01	H8768_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																								
H8768	008	0	1	04	01	H8768_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																								
H8768	008	0	1	04	01	H8768_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
H8768	008	0	1	04	01	H8768_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	008	0	1	04	01	H8768_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				170.00	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
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	0.00		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	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	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																								
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																											141.00						131.00				47.00				47.00		1.56						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	010	0	1	04	01	H8768_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				162.00	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
H8768	011	0	1	04	01	H8768_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																								
H8768	011	0	1	04	01	H8768_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																								
H8768	011	0	1	04	01	H8768_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
H8768	011	0	1	04	01	H8768_011_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	011	0	1	04	01	H8768_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				151.00	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
H8768	013	0	1	04	01	H8768_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																								
H8768	013	0	1	04	01	H8768_013_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																								
H8768	013	0	1	04	01	H8768_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
H8768	013	0	1	04	01	H8768_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	013	0	1	04	01	H8768_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				170.00	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
H8768	014	0	1	04	01	H8768_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																								
H8768	014	0	1	04	01	H8768_014_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																								
H8768	014	0	1	04	01	H8768_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
H8768	014	0	1	04	01	H8768_014_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	014	0	1	04	01	H8768_014_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H8768	016	0	1	04	01	H8768_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																								
H8768	016	0	1	04	01	H8768_016_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																								
H8768	016	0	1	04	01	H8768_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
H8768	016	0	1	04	01	H8768_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	016	0	1	04	01	H8768_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				178.00	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
H8768	017	1	1	04	01	H8768_017_1	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																								
H8768	017	1	1	04	01	H8768_017_1	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																								
H8768	017	1	1	04	01	H8768_017_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																											141.00						131.00				47.00				47.00		1.56						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	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	017	1	1	04	01	H8768_017_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H8768	017	2	1	04	01	H8768_017_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	017	2	1	04	01	H8768_017_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																								
H8768	017	2	1	04	01	H8768_017_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	017	2	1	04	01	H8768_017_2	5			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	017	2	1	04	01	H8768_017_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H8768	017	3	1	04	01	H8768_017_3	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																								
H8768	017	3	1	04	01	H8768_017_3	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																								
H8768	017	3	1	04	01	H8768_017_3	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
H8768	017	3	1	04	01	H8768_017_3	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	017	3	1	04	01	H8768_017_3	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
H8768	022	0	1	04	01	H8768_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																								
H8768	022	0	1	04	01	H8768_022_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																								
H8768	022	0	1	04	01	H8768_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
H8768	022	0	1	04	01	H8768_022_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	022	0	1	04	01	H8768_022_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				182.00	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
H8768	023	0	1	04	01	H8768_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																								
H8768	023	0	1	04	01	H8768_023_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																								
H8768	023	0	1	04	01	H8768_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
H8768	023	0	1	04	01	H8768_023_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	023	0	1	04	01	H8768_023_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				195.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				179.00	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
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			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			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				170.00	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
H8768	027	0	1	04	01	H8768_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																								
H8768	027	0	1	04	01	H8768_027_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	027	0	1	04	01	H8768_027_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	027	0	1	04	01	H8768_027_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	027	0	1	04	01	H8768_027_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				182.00	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
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			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	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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				199.00	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
H8768	034	0	1	04	01	H8768_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																								
H8768	034	0	1	04	01	H8768_034_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																								
H8768	034	0	1	04	01	H8768_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
H8768	034	0	1	04	01	H8768_034_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	034	0	1	04	01	H8768_034_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				175.00	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
H8768	035	0	1	04	01	H8768_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																								
H8768	035	0	1	04	01	H8768_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																								
H8768	035	0	1	04	01	H8768_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
H8768	035	0	1	04	01	H8768_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	035	0	1	04	01	H8768_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				152.00	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
H8768	037	1	1	04	01	H8768_037_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																								
H8768	037	1	1	04	01	H8768_037_1	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																								
H8768	037	1	1	04	01	H8768_037_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
H8768	037	1	1	04	01	H8768_037_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	037	1	1	04	01	H8768_037_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
H8768	037	2	1	04	01	H8768_037_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	037	2	1	04	01	H8768_037_2	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																								
H8768	037	2	1	04	01	H8768_037_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	037	2	1	04	01	H8768_037_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	037	2	1	04	01	H8768_037_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
H8768	038	1	1	04	01	H8768_038_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																								
H8768	038	1	1	04	01	H8768_038_1	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																								
H8768	038	1	1	04	01	H8768_038_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
H8768	038	1	1	04	01	H8768_038_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	038	1	1	04	01	H8768_038_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H8768	038	2	1	04	01	H8768_038_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	038	2	1	04	01	H8768_038_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																								
H8768	038	2	1	04	01	H8768_038_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	038	2	1	04	01	H8768_038_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	038	2	1	04	01	H8768_038_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
H8768	039	0	1	04	01	H8768_039_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	039	0	1	04	01	H8768_039_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																								
H8768	039	0	1	04	01	H8768_039_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	039	0	1	04	01	H8768_039_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	039	0	1	04	01	H8768_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				184.00	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
H8768	040	0	1	04	01	H8768_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																								
H8768	040	0	1	04	01	H8768_040_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																								
H8768	040	0	1	04	01	H8768_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
H8768	040	0	1	04	01	H8768_040_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	040	0	1	04	01	H8768_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				231.00	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
H8768	042	0	1	04	01	H8768_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																								
H8768	042	0	1	04	01	H8768_042_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																								
H8768	042	0	1	04	01	H8768_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
H8768	042	0	1	04	01	H8768_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	042	0	1	04	01	H8768_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				176.00	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
H8768	046	0	1	04	01	H8768_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																								
H8768	046	0	1	04	01	H8768_046_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																								
H8768	046	0	1	04	01	H8768_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
H8768	046	0	1	04	01	H8768_046_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	046	0	1	04	01	H8768_046_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				194.00	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
H8768	050	0	1	04	01	H8768_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																								
H8768	050	0	1	04	01	H8768_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																								
H8768	050	0	1	04	01	H8768_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
H8768	050	0	1	04	01	H8768_050_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	050	0	1	04	01	H8768_050_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				170.00	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
H8768	052	1	1	04	01	H8768_052_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																								
H8768	052	1	1	04	01	H8768_052_1	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																								
H8768	052	1	1	04	01	H8768_052_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
H8768	052	1	1	04	01	H8768_052_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	052	1	1	04	01	H8768_052_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
H8768	052	2	1	04	01	H8768_052_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	052	2	1	04	01	H8768_052_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																								
H8768	052	2	1	04	01	H8768_052_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	052	2	1	04	01	H8768_052_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	052	2	1	04	01	H8768_052_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				167.00	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
H8768	055	1	1	04	01	H8768_055_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																								
H8768	055	1	1	04	01	H8768_055_1	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																								
H8768	055	1	1	04	01	H8768_055_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
H8768	055	1	1	04	01	H8768_055_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	055	1	1	04	01	H8768_055_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
H8768	055	2	1	04	01	H8768_055_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	055	2	1	04	01	H8768_055_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																								
H8768	055	2	1	04	01	H8768_055_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	055	2	1	04	01	H8768_055_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	055	2	1	04	01	H8768_055_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				173.00	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
H8768	056	1	1	04	01	H8768_056_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																								
H8768	056	1	1	04	01	H8768_056_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																								
H8768	056	1	1	04	01	H8768_056_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
H8768	056	1	1	04	01	H8768_056_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	056	1	1	04	01	H8768_056_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				148.00	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
H8768	056	2	1	04	01	H8768_056_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	056	2	1	04	01	H8768_056_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	056	2	1	04	01	H8768_056_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	056	2	1	04	01	H8768_056_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	056	2	1	04	01	H8768_056_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				148.00	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
H8768	057	1	1	04	01	H8768_057_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																								
H8768	057	1	1	04	01	H8768_057_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																								
H8768	057	1	1	04	01	H8768_057_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
H8768	057	1	1	04	01	H8768_057_1	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	057	1	1	04	01	H8768_057_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				144.00	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
H8768	057	2	1	04	01	H8768_057_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	057	2	1	04	01	H8768_057_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	057	2	1	04	01	H8768_057_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	057	2	1	04	01	H8768_057_2	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	057	2	1	04	01	H8768_057_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				144.00	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
H8768	058	0	1	04	01	H8768_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																								
H8768	058	0	1	04	01	H8768_058_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																								
H8768	058	0	1	04	01	H8768_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
H8768	058	0	1	04	01	H8768_058_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
H8768	058	0	1	04	01	H8768_058_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				177.00	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
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	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																								
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										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			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1705.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8783	002	0	1	04	01	H8783_002_0	12			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	12			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	12			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	12			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										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	12			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										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			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1635.00	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8794	001	0	1	01	01	H8794_001_0	7		N	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	001	0	1	01	01	H8794_001_0	7		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				5.00	23	23	23																		0	0	0															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										12.00	24.00	36.00				0.00	0.00	0.00				12.00		12.00
H8794	001	0	1	01	01	H8794_001_0	7		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				79.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8794	001	0	1	01	01	H8794_001_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				120.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8794	001	0	1	01	01	H8794_001_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8794	001	0	1	01	01	H8794_001_0	7		N	Vaccines	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																								
H8794	002	0	1	01	01	H8794_002_0	7		N	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	002	0	1	01	01	H8794_002_0	7		N	Generic	4	01	1	2	2	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	002	0	1	01	01	H8794_002_0	7		N	Preferred Brand	4	10	1	2	3	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	002	0	1	01	01	H8794_002_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				82.00	18	18	18																		18	18	18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	002	0	1	01	01	H8794_002_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	002	0	1	01	01	H8794_002_0	7		N	Vaccines	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																								
H8794	004	0	1	01	01	H8794_004_0	7		N	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	004	0	1	01	01	H8794_004_0	7		N	Generic	4	01	1	2	2	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	004	0	1	01	01	H8794_004_0	7		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				78.00	23	23	23																		23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	004	0	1	01	01	H8794_004_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				111.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	004	0	1	01	01	H8794_004_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	004	0	1	01	01	H8794_004_0	7		N	Vaccines	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																								
H8794	005	0	1	01	01	H8794_005_0	7		N	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	005	0	1	01	01	H8794_005_0	7		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				1.00	3	3	3																		0	0	0															3			3								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	005	0	1	01	01	H8794_005_0	7		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				83.00	24	24	24																		22	22	22															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	005	0	1	01	01	H8794_005_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				118.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	005	0	1	01	01	H8794_005_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8794	005	0	1	01	01	H8794_005_0	7		N	Vaccines	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																								
H8797	003	0	1	02	01	H8797_003_0	6			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	6			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																								
H8797	003	0	1	02	01	H8797_003_0	6			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	6			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
H8797	003	0	1	02	01	H8797_003_0	6			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	6			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	6			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																								
H8797	004	0	1	02	01	H8797_004_0	6			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	6			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
H8797	004	0	1	02	01	H8797_004_0	6			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																								
H8823	001	0	1	01	01	H8823_001_0	8			Preferred Generic	4	01	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	5.00		12.50																			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																								
H8823	001	0	1	01	01	H8823_001_0	8			Generic	4	01	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	20.00		50.00																			0.00		0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8823	001	0	1	01	01	H8823_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		117.50																			42.00		84.00																47.00				47.00		1.57			1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50				35.00		70.00				35.00		35.00
H8823	001	0	1	01	01	H8823_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																			95.00		285.00																100.00				100.00		3.33			3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00		87.50				35.00		70.00				35.00		35.00
H8823	001	0	1	01	01	H8823_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1035.56	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8823	001	0	1	01	01	H8823_001_0	8			Select Care Drugs	4	01	1	2	6	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, Select Care Drugs																								
H8832	001	0	1	04	01	H8832_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
H8832	001	0	1	04	01	H8832_001_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
H8832	001	0	1	04	01	H8832_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
H8832	001	0	1	04	01	H8832_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
H8832	001	0	1	04	01	H8832_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				531.49	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8832	001	0	1	04	01	H8832_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																								
H8832	002	0	1	04	01	H8832_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8832	002	0	1	04	01	H8832_002_0	10			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
H8832	002	0	1	04	01	H8832_002_0	10			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
H8832	002	0	1	04	01	H8832_002_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	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
H8832	002	0	1	04	01	H8832_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				529.20	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H8832	002	0	1	04	01	H8832_002_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	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																								
H8849	001	0	1	02	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	02	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	02	01	H8849_001_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											123.89	25	25	25				99.12	20	20	20				20	20	20															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	70.00				35.00		35.00
H8849	001	0	1	02	01	H8849_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.13	25	25	25				56.13	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		35.00
H8849	001	0	1	02	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	02	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	003	0	1	02	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	02	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	02	01	H8849_003_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											126.57	25	25	25				101.26	20	20	20				20	20	20															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	70.00				35.00		35.00
H8849	003	0	1	02	01	H8849_003_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											63.19	25	25	25				63.19	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		35.00
H8849	003	0	1	02	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	02	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	005	0	1	02	01	H8849_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	02	01	H8849_005_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																								
H8849	005	0	1	02	01	H8849_005_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											105.24	25	25	25				84.19	20	20	20				20	20	20															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	70.00				35.00		35.00
H8849	005	0	1	02	01	H8849_005_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											69.78	25	25	25				69.78	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		35.00
H8849	005	0	1	02	01	H8849_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																								
H8849	005	0	1	02	01	H8849_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	006	0	1	02	01	H8849_006_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																								
H8849	006	0	1	02	01	H8849_006_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																								
H8849	006	0	1	02	01	H8849_006_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.43	20	20	20				50.43	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	70.00				35.00		35.00
H8849	006	0	1	02	01	H8849_006_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											60.91	35	35	35				60.91	35	35	35				35	35	35															35			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
H8849	006	0	1	02	01	H8849_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																								
H8849	006	0	1	02	01	H8849_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																								
H8849	009	0	1	02	01	H8849_009_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																								
H8849	009	0	1	02	01	H8849_009_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H8849	009	0	1	02	01	H8849_009_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.83	20	20	20				52.83	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	70.00				35.00		35.00
H8849	009	0	1	02	01	H8849_009_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											72.65	35	35	35				72.65	35	35	35				35	35	35															35			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
H8849	009	0	1	02	01	H8849_009_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																								
H8849	009	0	1	02	01	H8849_009_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																								
H8849	013	0	1	02	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	02	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	02	01	H8849_013_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											97.97	25	25	25				78.38	20	20	20				20	20	20															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	70.00				35.00		35.00
H8849	013	0	1	02	01	H8849_013_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.56	25	25	25				64.56	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		35.00
H8849	013	0	1	02	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	02	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
H8879	001	0	1	01	01	H8879_001_0	8			Preferred Generic	4	01	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		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8879	001	0	1	01	01	H8879_001_0	8			Generic	4	01	3	2	2	1		110	01		110	1				30		100	1	2				30		100	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										0.00		0.00	0.00		0.00	0.00		0.00	0.00		0.00	0.00		0.00
H8879	001	0	1	01	01	H8879_001_0	8			Preferred Brand	4	10	1	2	3	1		110	01		110	1				30		100	2	2				30		100	30		31								47.00		141.00					0.00		0.00											47.00		141.00				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										0.00		0.00	0.00		0.00	0.00		0.00	0.00		0.00	0.00		0.00
H8879	001	0	1	01	01	H8879_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					0.00		0.00											100.00		300.00				0.00		0.00				100.00				100.00			3.33	0.00		3.33	0.00	3.23	Preferred Generic, 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
H8879	001	0	1	01	01	H8879_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											750.00	33						750.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	001	0	1	04	01	H8889_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					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	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					11.00	22.00	33.00											20.00	40.00	60.00				11.00	22.00	33.00				20.00				11.00			0.67	0.37		0.67	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	001	0	1	04	01	H8889_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.12	22	22	22				77.09	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											102.59	50	50	50				64.78	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	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	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					11.00	22.00	33.00											20.00	40.00	60.00				11.00	22.00	33.00				20.00				11.00			0.67	0.37		0.67	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	002	0	1	04	01	H8889_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.26	22	22	22				80.41	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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											79.50	50	50	50				67.02	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
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					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	003	0	1	04	01	H8889_003_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.61	25	25	25				69.05	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
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											63.37	50	50	50				53.95	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					13.00	26.00	39.00											20.00	40.00	60.00				13.00	26.00	39.00				20.00				13.00			0.67	0.43		0.67	0.43	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	004	0	1	04	01	H8889_004_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											60.41	20	20	20				66.38	20	20	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	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											93.13	50	50	50				61.17	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					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																								
H8889	005	0	1	04	01	H8889_005_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.79	17	17	17				63.02	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
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											90.90	50	50	50				69.72	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
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												27							27												27						27					27			27								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					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																								
H8889	008	0	1	04	01	H8889_008_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.91	18	18	18				64.39	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
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											88.93	50	50	50				67.64	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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	010	0	1	04	01	H8889_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	0.00	0.00	0.00																			0.00	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	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	45.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	010	0	1	04	01	H8889_010_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				67.85	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		35.00
H8889	010	0	1	04	01	H8889_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				54.46	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
H8889	010	0	1	04	01	H8889_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																								
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	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																								
H8889	011	0	1	04	01	H8889_011_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.56	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
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				54.17	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	6			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	6			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	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																								
H8889	012	0	1	04	01	H8889_012_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				81.67	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		35.00
H8889	012	0	1	04	01	H8889_012_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				72.21	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	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																								
H8889	013	0	1	04	01	H8889_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	0.00	0.00	0.00																			0.00	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	6			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	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																								
H8889	013	0	1	04	01	H8889_013_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				68.09	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
H8889	013	0	1	04	01	H8889_013_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				72.21	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	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																								
H8889	014	0	1	04	01	H8889_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	0.00	0.00	0.00																			0.00	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	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	45.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8889	014	0	1	04	01	H8889_014_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				65.54	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
H8889	014	0	1	04	01	H8889_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				77.97	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	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					27																				27																	27			27								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	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																								
H8889	015	0	1	04	01	H8889_015_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				77.79	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
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				58.44	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	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																								
H8902	001	0	1	01	01	H8902_001_0	9			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																								
H8902	001	0	1	01	01	H8902_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H8902	001	0	1	01	01	H8902_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											95.04	50	50	50				95.04	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
H8902	001	0	1	01	01	H8902_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																								
H8902	002	0	1	01	01	H8902_002_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																								
H8902	002	0	1	01	01	H8902_002_0	9			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																								
H8902	002	0	1	01	01	H8902_002_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	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										0.00	0.00	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.05	50	50	50				90.05	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
H8902	002	0	1	01	01	H8902_002_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																								
H8902	005	0	1	01	01	H8902_005_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																								
H8902	005	0	1	01	01	H8902_005_0	9			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																								
H8902	005	0	1	01	01	H8902_005_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	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	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H8902	005	0	1	01	01	H8902_005_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											97.62	50	50	50				97.62	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
H8902	005	0	1	01	01	H8902_005_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																								
H8902	006	0	1	01	01	H8902_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H8902	006	0	1	01	01	H8902_006_0	9			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																								
H8902	006	0	1	01	01	H8902_006_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	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										0.00	0.00	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	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.89	50	50	50				88.89	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
H8902	006	0	1	01	01	H8902_006_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																								
H8902	009	0	1	01	01	H8902_009_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																								
H8902	009	0	1	01	01	H8902_009_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																								
H8902	009	0	1	01	01	H8902_009_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											106.53	25	25	25				106.53	24	24	24										25	25	25				24	24	24			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
H8902	009	0	1	01	01	H8902_009_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											86.12	45	45	45				86.12	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
H8902	009	0	1	01	01	H8902_009_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																								
H8902	010	0	1	01	01	H8902_010_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																								
H8902	010	0	1	01	01	H8902_010_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																								
H8902	010	0	1	01	01	H8902_010_0	8			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H8902	010	0	1	01	01	H8902_010_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											89.54	50	50	50				89.54	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
H8902	010	0	1	01	01	H8902_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																								
H8902	011	0	1	01	01	H8902_011_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																								
H8902	011	0	1	01	01	H8902_011_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																								
H8902	011	0	1	01	01	H8902_011_0	8			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	129.00					42.00	84.00	126.00											43.00	86.00	129.00				42.00	84.00	126.00				43.00				43.00			1.43	1.40		1.43	1.40	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00	70.00	85.00	35.00		35.00
H8902	011	0	1	01	01	H8902_011_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											89.05	50	50	50				89.05	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
H8902	011	0	1	01	01	H8902_011_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																								
H8908	001	0	1	02	01	H8908_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																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, 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	4			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	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		95.00	35.00		35.00
H8908	001	0	1	02	01	H8908_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H8908	001	0	1	02	01	H8908_001_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
H8908	002	0	1	01	01	H8908_002_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
H8908	002	0	1	01	01	H8908_002_0	4			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	002	0	1	01	01	H8908_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		95.00	35.00		35.00
H8908	002	0	1	01	01	H8908_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00
H8908	002	0	1	01	01	H8908_002_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
H8908	004	0	1	02	01	H8908_004_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
H8908	004	0	1	02	01	H8908_004_0	4			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	004	0	1	02	01	H8908_004_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		95.00	35.00		35.00
H8908	004	0	1	02	01	H8908_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				97.00	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		35.00
H8908	004	0	1	02	01	H8908_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
H8908	006	0	1	01	01	H8908_006_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
H8908	006	0	1	01	01	H8908_006_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, Select Care Drugs										0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H8908	006	0	1	01	01	H8908_006_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		95.00	35.00		35.00
H8908	006	0	1	01	01	H8908_006_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	46		46																								46		46				46		46			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		35.00
H8908	006	0	1	01	01	H8908_006_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
H8908	006	0	1	01	01	H8908_006_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
H8917	001	0	1	04	01	H8917_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8917	001	0	1	04	01	H8917_001_0	7			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
H8917	001	0	1	04	01	H8917_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H8917	001	0	1	04	01	H8917_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				45.00	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
H8917	001	0	1	04	01	H8917_001_0	7			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
H8917	002	0	1	04	01	H8917_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8917	002	0	1	04	01	H8917_002_0	7			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
H8917	002	0	1	04	01	H8917_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				58.00	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
H8917	002	0	1	04	01	H8917_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				45.00	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
H8917	002	0	1	04	01	H8917_002_0	7			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
H8947	001	1	1	04	01	H8947_001_1	9			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	9			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					4.00		12.00					4.00		12.00																20.00				20.00			0.67	0.13	0.13			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8947	001	1	1	04	01	H8947_001_1	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					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	9			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										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	9			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1217.50	33						1217.50	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8947	001	2	1	04	01	H8947_001_2	9			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	9			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					4.00		12.00					4.00		12.00																20.00				20.00			0.67	0.13	0.13			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8947	001	2	1	04	01	H8947_001_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					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	9			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										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	9			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1217.50	33						1217.50	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8947	002	1	1	04	01	H8947_002_1	9			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	9			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					4.00		12.00					4.00		12.00																20.00				20.00			0.67	0.13	0.13			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8947	002	1	1	04	01	H8947_002_1	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					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	9			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										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	9			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1219.01	33						1219.01	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8947	002	2	1	04	01	H8947_002_2	10			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	10			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					4.00		12.00					4.00		12.00																20.00				20.00			0.67	0.13	0.13			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8947	002	2	1	04	01	H8947_002_2	10			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	10			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										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	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1219.01	33						1219.01	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																								
H8967	002	0	1	01	01	H8967_002_0	4			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	4			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										10.00	20.00	30.00										10.00		10.00
H8967	002	0	1	01	01	H8967_002_0	4			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				2	2								10	31	45.00	90.00	105.00																																						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	4			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	4			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31				469.77	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	4			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																								
H9001	030	15	1	01	01	H9001_030_15	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, Select Care Drugs																								
H9001	030	15	1	01	01	H9001_030_15	11			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	11			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	030	15	1	01	01	H9001_030_15	11			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	030	15	1	01	01	H9001_030_15	11			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, Select Care Drugs																								
H9001	030	15	1	01	01	H9001_030_15	11			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	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, Select Care Drugs																								
H9001	030	16	1	01	01	H9001_030_16	11			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	11			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	030	16	1	01	01	H9001_030_16	11			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	030	16	1	01	01	H9001_030_16	11			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, Select Care Drugs																								
H9001	030	16	1	01	01	H9001_030_16	11			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	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, Select Care Drugs																								
H9001	030	18	1	01	01	H9001_030_18	11			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	11			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	030	18	1	01	01	H9001_030_18	11			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	030	18	1	01	01	H9001_030_18	11			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, Select Care Drugs																								
H9001	030	18	1	01	01	H9001_030_18	11			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	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, Select Care Drugs																								
H9001	031	15	1	01	01	H9001_031_15	11			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	11			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	031	15	1	01	01	H9001_031_15	11			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	031	15	1	01	01	H9001_031_15	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, Select Care Drugs																								
H9001	031	15	1	01	01	H9001_031_15	11			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	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, Select Care Drugs																								
H9001	031	16	1	01	01	H9001_031_16	11			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	11			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	031	16	1	01	01	H9001_031_16	11			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	031	16	1	01	01	H9001_031_16	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, Select Care Drugs																								
H9001	031	16	1	01	01	H9001_031_16	11			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	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, Select Care Drugs																								
H9001	031	18	1	01	01	H9001_031_18	11			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	11			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	031	18	1	01	01	H9001_031_18	11			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	031	18	1	01	01	H9001_031_18	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, Select Care Drugs																								
H9001	031	18	1	01	01	H9001_031_18	11			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	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, Select Care Drugs																								
H9001	038	0	1	01	01	H9001_038_0	10			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	10			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	038	0	1	01	01	H9001_038_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				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	038	0	1	01	01	H9001_038_0	10			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																								
H9001	038	0	1	01	01	H9001_038_0	10			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	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9003	001	0	1	02	01	H9003_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	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	9			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										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	9			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										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	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										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	9			Vaccines	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																								
H9003	006	0	1	02	01	H9003_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	0.00	0.00	0.00																			0.00	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9003	006	0	1	02	01	H9003_006_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	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	9			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										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	9			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										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	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										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	9			Vaccines	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																								
H9003	008	0	1	02	01	H9003_008_0	8			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										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	8			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										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	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					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										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	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					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										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	8			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										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	8			Vaccines	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																								
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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9003	009	0	1	02	01	H9003_009_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	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			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										3.00	6.00	9.00				3.00	6.00	6.00				3.00		3.00
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										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										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										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	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																								
H9042	002	1	1	04	01	H9042_002_1	9			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 Brand, 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	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					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 Brand, 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	9			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					41.00	82.00	123.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.37	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
H9042	002	1	1	04	01	H9042_002_1	9			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											98.86	28	28	28				96.36	28	28	28				28	28	28																28		28								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
H9042	002	1	1	04	01	H9042_002_1	9			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												30							30																								30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00			35.00									35.00		35.00
H9042	002	1	1	04	01	H9042_002_1	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			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	0.00				0.00		0.00
H9042	002	2	1	04	01	H9042_002_2	9			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 Brand, 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	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					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 Brand, 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	9			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					41.00	82.00	123.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.37	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
H9042	002	2	1	04	01	H9042_002_2	9			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											98.86	28	28	28				96.36	28	28	28				28	28	28																28		28								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
H9042	002	2	1	04	01	H9042_002_2	9			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												30							30																								30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										35.00			35.00									35.00		35.00
H9042	002	2	1	04	01	H9042_002_2	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			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	0.00				0.00		0.00
H9047	013	0	2	01	01	H9047_013_0	7			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	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					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	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	95.00				35.00		35.00
H9047	013	0	2	01	01	H9047_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					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	70.00	105.00	35.00	70.00	95.00				35.00		35.00
H9047	013	0	2	01	01	H9047_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											630.59	33						834.30	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			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					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																								
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								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	95.00				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	70.00	105.00	35.00	70.00	95.00				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											904.31	30						696.57	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9047	054	0	1	01	01	H9047_054_0	7			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	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					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																								
H9047	054	0	1	01	01	H9047_054_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	95.00				35.00		35.00
H9047	054	0	1	01	01	H9047_054_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	95.00				35.00		35.00
H9047	054	0	1	01	01	H9047_054_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											688.74	30						807.09	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9047	059	0	1	02	01	H9047_059_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	059	0	1	02	01	H9047_059_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	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																								
H9047	059	0	1	02	01	H9047_059_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	95.00				35.00		35.00
H9047	059	0	1	02	01	H9047_059_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	70.00	105.00	35.00	70.00	95.00				35.00		35.00
H9047	059	0	1	02	01	H9047_059_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											497.57	33						802.13	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9047	062	0	1	02	01	H9047_062_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	062	0	1	02	01	H9047_062_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	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																								
H9047	062	0	1	02	01	H9047_062_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	95.00				35.00		35.00
H9047	062	0	1	02	01	H9047_062_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	70.00	105.00	35.00	70.00	95.00				35.00		35.00
H9047	062	0	1	02	01	H9047_062_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1276.64	33						1025.93	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9047	063	0	1	01	01	H9047_063_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	063	0	1	01	01	H9047_063_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	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																								
H9047	063	0	1	01	01	H9047_063_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	95.00				35.00		35.00
H9047	063	0	1	01	01	H9047_063_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	70.00	105.00	35.00	70.00	95.00				35.00		35.00
H9047	063	0	1	01	01	H9047_063_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											576.81	30						702.05	30						30																	30			30								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			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					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																								
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								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	95.00				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	70.00	105.00	35.00	70.00	95.00				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											637.05	33						795.97	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9047	065	0	1	02	01	H9047_065_0	7			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	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					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																								
H9047	065	0	1	02	01	H9047_065_0	7			Preferred Brand	4	11	3	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	95.00				35.00		35.00
H9047	065	0	1	02	01	H9047_065_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	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	70.00	105.00	35.00	70.00	95.00				35.00		35.00
H9047	065	0	1	02	01	H9047_065_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1082.19	33						884.68	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9047	066	0	1	01	01	H9047_066_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	066	0	1	01	01	H9047_066_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					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	8			Preferred Brand	4	11	3	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	95.00				35.00		35.00
H9047	066	0	1	01	01	H9047_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	300.00					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	95.00				35.00		35.00
H9047	066	0	1	01	01	H9047_066_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1070.07	33						769.58	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9065	002	0	1	02	01	H9065_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								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	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																								
H9065	002	0	1	02	01	H9065_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											90.85	25	25	25				72.68	20	20	20				20	20	20															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	70.00				35.00		35.00
H9065	002	0	1	02	01	H9065_002_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											66.41	35	35	35				66.41	35	35	35				35	35	35															35			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
H9065	002	0	1	02	01	H9065_002_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																								
H9065	002	0	1	02	01	H9065_002_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																								
H9065	003	0	1	02	01	H9065_003_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																								
H9065	003	0	1	02	01	H9065_003_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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																								
H9065	003	0	1	02	01	H9065_003_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.75	20	20	20				72.75	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	70.00				35.00		35.00
H9065	003	0	1	02	01	H9065_003_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											73.17	35	35	35				73.17	35	35	35				35	35	35															35			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
H9065	003	0	1	02	01	H9065_003_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																								
H9065	003	0	1	02	01	H9065_003_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																								
H9065	006	0	1	02	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9065	006	0	1	02	01	H9065_006_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.89	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9065	006	0	1	02	01	H9065_006_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				79.97	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
H9065	006	0	1	02	01	H9065_006_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				43.74	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
H9065	006	0	1	02	01	H9065_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9065	006	0	1	02	01	H9065_006_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																								
H9065	007	0	1	02	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9065	007	0	1	02	01	H9065_007_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.72	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9065	007	0	1	02	01	H9065_007_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				80.64	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
H9065	007	0	1	02	01	H9065_007_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				41.17	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
H9065	007	0	1	02	01	H9065_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				10.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9065	007	0	1	02	01	H9065_007_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																								
H9065	008	0	1	02	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								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	008	0	1	02	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								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	02	01	H9065_008_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											71.12	20	20	20				71.12	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	70.00				35.00		35.00
H9065	008	0	1	02	01	H9065_008_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											53.26	35	35	35				53.26	35	35	35				35	35	35															35			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
H9065	008	0	1	02	01	H9065_008_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																								
H9065	008	0	1	02	01	H9065_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																								
H9096	001	0	1	02	01	H9096_001_0	5			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					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																								
H9096	001	0	1	02	01	H9096_001_0	5			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	16.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	16.00				13.00		13.00
H9096	001	0	1	02	01	H9096_001_0	5			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											108.90	25	25	25				83.00	20	20	20				20	20	20																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											71.16	50	50	50				75.31	45	45	45				45	45	45																50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												29	31												29							29																								29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																								
H9096	001	0	1	02	01	H9096_001_0	5			Vaccines	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																								
H9096	002	0	1	02	01	H9096_002_0	5			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					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																								
H9096	002	0	1	02	01	H9096_002_0	5			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	16.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	16.00				13.00		13.00
H9096	002	0	1	02	01	H9096_002_0	5			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											105.27	25	25	25				81.29	20	20	20				20	20	20																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											71.11	50	50	50				59.54	45	45	45				45	45	45																50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												29	31												30							30																								30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																								
H9096	002	0	1	02	01	H9096_002_0	5			Vaccines	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																								
H9096	004	0	1	01	01	H9096_004_0	5			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					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																								
H9096	004	0	1	01	01	H9096_004_0	5			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	16.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	16.00				13.00		13.00
H9096	004	0	1	01	01	H9096_004_0	5			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											101.76	25	25	25				80.95	20	20	20				20	20	20																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											66.19	50	50	50				63.62	45	45	45				45	45	45																50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												29	31												28							28																								28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																								
H9096	004	0	1	01	01	H9096_004_0	5			Vaccines	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																								
H9096	005	0	1	01	01	H9096_005_0	5			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					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																								
H9096	005	0	1	01	01	H9096_005_0	5			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	16.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	16.00				13.00		13.00
H9096	005	0	1	01	01	H9096_005_0	5			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											105.93	25	25	25				80.58	20	20	20				20	20	20																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											57.65	50	50	50				50.22	45	45	45				45	45	45																50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	5			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												29	31												33							33																								33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																								
H9096	005	0	1	01	01	H9096_005_0	5			Vaccines	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																								
H9147	001	0	1	02	01	H9147_001_0	17		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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9147	001	0	1	02	01	H9147_001_0	17		N	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
H9147	001	0	1	02	01	H9147_001_0	17		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				62.50	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
H9147	001	0	1	02	01	H9147_001_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				61.13	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
H9147	001	0	1	02	01	H9147_001_0	17		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																								
H9147	001	0	1	02	01	H9147_001_0	17		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																								
H9179	001	0	1	01	01	H9179_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				47.05	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	70.00				35.00		35.00
H9179	001	0	1	01	01	H9179_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				87.08	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
H9179	001	0	1	01	01	H9179_001_0	6			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	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										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	6			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	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				61.10	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	70.00				35.00		35.00
H9179	002	0	1	01	01	H9179_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				90.95	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
H9179	002	0	1	01	01	H9179_002_0	6			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	01	01	H9207_002_0	21			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																								
H9207	002	0	1	01	01	H9207_002_0	21			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	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9207	002	0	1	01	01	H9207_002_0	21			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H9207	002	0	1	01	01	H9207_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				100.00	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	70.00				35.00		35.00
H9207	002	0	1	01	01	H9207_002_0	21			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										35.00						35.00						35.00		35.00
H9207	012	0	1	01	01	H9207_012_0	22			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																								
H9207	012	0	1	01	01	H9207_012_0	22			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	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																								
H9207	012	0	1	01	01	H9207_012_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H9207	012	0	1	01	01	H9207_012_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				100.00	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	70.00				35.00		35.00
H9207	012	0	1	01	01	H9207_012_0	22			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										35.00						35.00						35.00		35.00
H9207	013	0	1	01	01	H9207_013_0	22			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																								
H9207	013	0	1	01	01	H9207_013_0	22			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	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																								
H9207	013	0	1	01	01	H9207_013_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H9207	013	0	1	01	01	H9207_013_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				100.00	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	70.00				35.00		35.00
H9207	013	0	1	01	01	H9207_013_0	22			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										35.00						35.00						35.00		35.00
H9207	014	0	1	01	01	H9207_014_0	22			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																								
H9207	014	0	1	01	01	H9207_014_0	22			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	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																								
H9207	014	0	1	01	01	H9207_014_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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	70.00				35.00		35.00
H9207	014	0	1	01	01	H9207_014_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				100.00	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	70.00				35.00		35.00
H9207	014	0	1	01	01	H9207_014_0	22			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										35.00						35.00						35.00		35.00
H9207	015	0	1	01	01	H9207_015_0	22			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																								
H9207	015	0	1	01	01	H9207_015_0	22			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	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																								
H9207	015	0	1	01	01	H9207_015_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.00	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
H9207	015	0	1	01	01	H9207_015_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				100.00	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	70.00				35.00		35.00
H9207	015	0	1	01	01	H9207_015_0	22			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1011.73	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H9219	001	0	1	04	01	H9219_001_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																								
H9219	001	0	1	04	01	H9219_001_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																								
H9219	001	0	1	04	01	H9219_001_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											81.00	25	25	25				64.80	20	20	20				20	20	20															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	70.00				35.00		35.00
H9219	001	0	1	04	01	H9219_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.59	35	35	35				52.59	35	35	35				35	35	35															35			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
H9219	001	0	1	04	01	H9219_001_0	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, Select Care Drugs																								
H9219	001	0	1	04	01	H9219_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																								
H9231	001	0	1	04	01	H9231_001_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										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	7			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
H9231	001	0	1	04	01	H9231_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H9231	001	0	1	04	01	H9231_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				37.00	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
H9231	001	0	1	04	01	H9231_001_0	7			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
H9231	002	0	1	04	01	H9231_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										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	7			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	002	0	1	04	01	H9231_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				73.00	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
H9231	002	0	1	04	01	H9231_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				38.00	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
H9231	002	0	1	04	01	H9231_002_0	7			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
H9231	005	0	1	04	01	H9231_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										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	7			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
H9231	005	0	1	04	01	H9231_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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
H9231	005	0	1	04	01	H9231_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				38.00	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
H9231	005	0	1	04	01	H9231_005_0	7			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
H9231	006	0	1	04	01	H9231_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										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	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																			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	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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
H9231	006	0	1	04	01	H9231_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				38.00	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
H9231	006	0	1	04	01	H9231_006_0	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
H9231	007	0	1	04	01	H9231_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	Preferred Generic, 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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H9231	007	0	1	04	01	H9231_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				38.00	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
H9231	007	0	1	04	01	H9231_007_0	7			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
H9231	010	0	1	04	01	H9231_010_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.00	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
H9231	010	0	1	04	01	H9231_010_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				38.00	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
H9231	010	0	1	04	01	H9231_010_0	7			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
H9231	011	0	1	04	01	H9231_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	011	0	1	04	01	H9231_011_0	7			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
H9231	011	0	1	04	01	H9231_011_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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
H9231	011	0	1	04	01	H9231_011_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				45.00	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
H9231	011	0	1	04	01	H9231_011_0	7			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
H9231	012	0	1	04	01	H9231_012_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	012	0	1	04	01	H9231_012_0	7			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
H9231	012	0	1	04	01	H9231_012_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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
H9231	012	0	1	04	01	H9231_012_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				45.00	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
H9231	012	0	1	04	01	H9231_012_0	7			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
H9239	001	0	1	48	05	H9239_001_0	5			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	5			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	5			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															
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	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
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	008	1	1	01	01	H9306_008_1	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																								
H9306	008	1	1	01	01	H9306_008_1	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	008	1	1	01	01	H9306_008_1	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	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
H9306	008	1	1	01	01	H9306_008_1	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	008	1	1	01	01	H9306_008_1	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	008	2	1	01	01	H9306_008_2	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																								
H9306	008	2	1	01	01	H9306_008_2	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	008	2	1	01	01	H9306_008_2	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	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
H9306	008	2	1	01	01	H9306_008_2	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	008	2	1	01	01	H9306_008_2	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	009	1	1	01	01	H9306_009_1	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																								
H9306	009	1	1	01	01	H9306_009_1	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9306	009	1	1	01	01	H9306_009_1	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	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
H9306	009	1	1	01	01	H9306_009_1	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	009	1	1	01	01	H9306_009_1	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				194.04	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9306	009	2	1	01	01	H9306_009_2	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																								
H9306	009	2	1	01	01	H9306_009_2	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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9306	009	2	1	01	01	H9306_009_2	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	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
H9306	009	2	1	01	01	H9306_009_2	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	009	2	1	01	01	H9306_009_2	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				194.04	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9364	001	0	1	02	01	H9364_001_0	5			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	02	01	H9364_001_0	5			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																								
H9364	001	0	1	02	01	H9364_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.66	25	25	25				155.66	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
H9364	001	0	1	02	01	H9364_001_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											53.81	43	43	43				53.81	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
H9364	001	0	1	02	01	H9364_001_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, Select Care Drugs																								
H9364	001	0	1	02	01	H9364_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	0.00				0.00				0.00			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	02	01	H9364_004_0	5			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	02	01	H9364_004_0	5			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																								
H9364	004	0	1	02	01	H9364_004_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											155.29	25	25	25				155.29	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
H9364	004	0	1	02	01	H9364_004_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											57.80	50	50	50				57.80	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
H9364	004	0	1	02	01	H9364_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, Select Care Drugs																								
H9364	004	0	1	02	01	H9364_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		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			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	5			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	5			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																								
H9387	001	0	1	04	01	H9387_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.22	25	25	25				159.22	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
H9387	001	0	1	04	01	H9387_001_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											64.86	40	40	40				64.86	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
H9387	001	0	1	04	01	H9387_001_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, Select Care Drugs																								
H9387	001	0	1	04	01	H9387_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9387	004	0	1	04	01	H9387_004_0	5		N	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					9.00	18.00	27.00											19.00	38.00	57.00				9.00	18.00	0.00				19.00				19.00			0.63	0.3		0.63	0.3	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9387	004	0	1	04	01	H9387_004_0	5		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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9387	004	0	1	04	01	H9387_004_0	5		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											113.35	19	19	19				113.35	19	19	19										19	19	19				19	19	19			19			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	70.00	105.00	35.00		35.00
H9387	004	0	1	04	01	H9387_004_0	5		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											35.35	36	36	36				35.35	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
H9387	004	0	1	04	01	H9387_004_0	5		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, Select Care Drugs																								
H9387	004	0	1	04	01	H9387_004_0	5		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	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9431	014	0	1	04	01	H9431_014_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H9431	014	0	1	04	01	H9431_014_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H9431	014	0	1	04	01	H9431_014_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.81	24	24	24				94.07	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
H9431	014	0	1	04	01	H9431_014_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.57	25	25	25				30.49	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
H9431	014	0	1	04	01	H9431_014_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											672.75	25						729.26	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
H9431	018	0	1	04	01	H9431_018_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
H9431	018	0	1	04	01	H9431_018_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					10.00	20.00	30.00											12.00	24.00	36.00				10.00	20.00	20.00					12.00			12.00			0.40	0.33		0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9431	018	0	1	04	01	H9431_018_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.33	25	25	25				94.24	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
H9431	018	0	1	04	01	H9431_018_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.21	26	26	26				33.12	26	26	26										26	26	26				26	26	26				26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											842.13	30						818.12	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
H9460	001	0	1	01	01	H9460_001_0	4			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
H9460	001	0	1	01	01	H9460_001_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											807.75	33						661.72	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
H9469	001	0	1	04	01	H9469_001_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H9469	001	0	1	04	01	H9469_001_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, Supplemental Drugs																								
H9469	001	0	1	04	01	H9469_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								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, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9469	001	0	1	04	01	H9469_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30					30						30		34											109.71	25						109.71	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H9469	001	0	1	04	01	H9469_001_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, Supplemental Drugs																								
H9469	001	0	1	04	01	H9469_001_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H9469	002	0	1	04	01	H9469_002_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H9469	002	0	1	04	01	H9469_002_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, Supplemental Drugs																								
H9469	002	0	1	04	01	H9469_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	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, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9469	002	0	1	04	01	H9469_002_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30					30						30		34											96.19	25						96.19	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H9469	002	0	1	04	01	H9469_002_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, Supplemental Drugs																								
H9469	002	0	1	04	01	H9469_002_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H9469	003	0	1	04	01	H9469_003_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H9469	003	0	1	04	01	H9469_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					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, Supplemental Drugs																								
H9469	003	0	1	04	01	H9469_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	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, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9469	003	0	1	04	01	H9469_003_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30					30						30		34											94.26	25						94.26	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H9469	003	0	1	04	01	H9469_003_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, Supplemental Drugs																								
H9469	003	0	1	04	01	H9469_003_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H9469	006	0	1	04	01	H9469_006_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H9469	006	0	1	04	01	H9469_006_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, Supplemental Drugs																								
H9469	006	0	1	04	01	H9469_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	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, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9469	006	0	1	04	01	H9469_006_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30					30						30		34											95.00	25						95.00	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H9469	006	0	1	04	01	H9469_006_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, Supplemental Drugs																								
H9469	006	0	1	04	01	H9469_006_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H9469	007	0	1	04	01	H9469_007_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H9469	007	0	1	04	01	H9469_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					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, Supplemental Drugs																								
H9469	007	0	1	04	01	H9469_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, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9469	007	0	1	04	01	H9469_007_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30					30						30		34											101.06	25						101.06	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H9469	007	0	1	04	01	H9469_007_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, Supplemental Drugs																								
H9469	007	0	1	04	01	H9469_007_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H9469	008	0	1	04	01	H9469_008_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H9469	008	0	1	04	01	H9469_008_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, Supplemental Drugs																								
H9469	008	0	1	04	01	H9469_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, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9469	008	0	1	04	01	H9469_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30					30						30		34											93.27	25						93.27	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H9469	008	0	1	04	01	H9469_008_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, Supplemental Drugs																								
H9469	008	0	1	04	01	H9469_008_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H9469	009	0	1	04	01	H9469_009_0	7			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 Drug, Specialty Tier, Supplemental Drugs																								
H9469	009	0	1	04	01	H9469_009_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, Supplemental Drugs																								
H9469	009	0	1	04	01	H9469_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, Supplemental Drugs										35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9469	009	0	1	04	01	H9469_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30					30						30		34											92.07	25						92.07	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										35.00			35.00			35.00						35.00		35.00
H9469	009	0	1	04	01	H9469_009_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, Supplemental Drugs																								
H9469	009	0	1	04	01	H9469_009_0	7			Supplemental Drugs	4	01	2	2	6	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, Supplemental Drugs																								
H9485	001	0	1	04	01	H9485_001_0	8			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																								
H9485	001	0	1	04	01	H9485_001_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																			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																								
H9485	001	0	1	04	01	H9485_001_0	8			Preferred Brand	4	11	3	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
H9485	001	0	1	04	01	H9485_001_0	8			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	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	8			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	8			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																								
H9485	002	0	1	04	01	H9485_002_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																			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																								
H9485	002	0	1	04	01	H9485_002_0	8			Preferred Brand	4	11	3	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
H9485	002	0	1	04	01	H9485_002_0	8			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	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	8			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
H9485	003	0	1	04	01	H9485_003_0	8			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																								
H9485	003	0	1	04	01	H9485_003_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																			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																								
H9485	003	0	1	04	01	H9485_003_0	8			Preferred Brand	4	11	3	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
H9485	003	0	1	04	01	H9485_003_0	8			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	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	003	0	1	04	01	H9485_003_0	8			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	15			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	15			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	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																			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, 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	15			Non-Preferred Drug	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										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	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				881.92	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9489	001	0	1	01	01	H9489_001_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9525	004	0	1	02	01	H9525_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																								
H9525	004	0	1	02	01	H9525_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																								
H9525	004	0	1	02	01	H9525_004_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											67.55	25	25	25				54.04	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	004	0	1	02	01	H9525_004_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											56.61	40	40	40				56.61	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		35.00
H9525	004	0	1	02	01	H9525_004_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																								
H9525	004	0	1	02	01	H9525_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																								
H9525	006	0	1	02	01	H9525_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	02	01	H9525_006_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																								
H9525	006	0	1	02	01	H9525_006_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											67.87	25	25	25				54.30	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	006	0	1	02	01	H9525_006_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											60.25	45	45	45				60.25	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		35.00
H9525	006	0	1	02	01	H9525_006_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																								
H9525	006	0	1	02	01	H9525_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																								
H9525	011	0	1	02	01	H9525_011_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																								
H9525	011	0	1	02	01	H9525_011_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	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	02	01	H9525_011_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.28	25	25	25				40.22	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	011	0	1	02	01	H9525_011_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.06	25	25	25				56.06	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		35.00
H9525	011	0	1	02	01	H9525_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																								
H9525	011	0	1	02	01	H9525_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																								
H9525	013	1	1	02	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	02	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	02	01	H9525_013_1	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											45.38	25	25	25				36.30	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	013	1	1	02	01	H9525_013_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											36.45	40	40	40				36.45	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		35.00
H9525	013	1	1	02	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	02	01	H9525_013_1	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																								
H9525	013	2	1	02	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	02	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	02	01	H9525_013_2	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											45.38	25	25	25				36.30	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	013	2	1	02	01	H9525_013_2	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											36.45	40	40	40				36.45	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		35.00
H9525	013	2	1	02	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	02	01	H9525_013_2	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																								
H9525	013	3	1	02	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	02	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	02	01	H9525_013_3	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											45.38	25	25	25				36.30	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	013	3	1	02	01	H9525_013_3	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											36.45	40	40	40				36.45	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		35.00
H9525	013	3	1	02	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	02	01	H9525_013_3	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																								
H9525	013	4	1	02	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	02	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	02	01	H9525_013_4	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											45.38	25	25	25				36.30	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	013	4	1	02	01	H9525_013_4	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											36.45	40	40	40				36.45	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		35.00
H9525	013	4	1	02	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	02	01	H9525_013_4	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																								
H9525	015	0	1	02	01	H9525_015_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																								
H9525	015	0	1	02	01	H9525_015_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																								
H9525	015	0	1	02	01	H9525_015_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.93	25	25	25				51.94	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	015	0	1	02	01	H9525_015_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											49.24	35	35	35				49.24	35	35	35				35	35	35															35			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
H9525	015	0	1	02	01	H9525_015_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																								
H9525	015	0	1	02	01	H9525_015_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																								
H9525	017	0	1	02	01	H9525_017_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	017	0	1	02	01	H9525_017_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	017	0	1	02	01	H9525_017_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.34	25	25	25				46.67	20	20	20				20	20	20															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	70.00				35.00		35.00
H9525	017	0	1	02	01	H9525_017_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											41.64	40	40	40				41.64	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		35.00
H9525	017	0	1	02	01	H9525_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, Select Care Drugs																								
H9525	017	0	1	02	01	H9525_017_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																								
H9572	001	1	1	04	01	H9572_001_1	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											47.00	50		50				45.00	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	001	1	1	04	01	H9572_001_1	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											47.00	50		50				45.00	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	001	2	1	04	01	H9572_001_2	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											47.00	50		50				45.00	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	001	3	1	04	01	H9572_001_3	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											47.00	50		50				45.00	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	001	4	1	04	01	H9572_001_4	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											47.00	50		50				45.00	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	001	6	1	04	01	H9572_001_6	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											44.00	50		50				45.00	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	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											44.00	50		50				45.00	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	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											44.00	50		50				45.00	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	7			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	8			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	8			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	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		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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											44.00	50		50				45.00	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	8			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											44.00	50		50				45.00	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	7			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	8			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	8			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	8			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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	50		50				47.00	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	003	1	1	04	01	H9572_003_1	8			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	8			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	8			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	8			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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	50		50				47.00	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	003	2	1	04	01	H9572_003_2	8			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	8			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	8			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	8			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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	50		50				47.00	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	003	3	1	04	01	H9572_003_3	8			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	8			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	8			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	8			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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	50		50				47.00	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	003	4	1	04	01	H9572_003_4	8			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	8			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	8			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	8			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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	50		50				47.00	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	003	6	1	04	01	H9572_003_6	8			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	8			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	8			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	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		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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	8			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	8			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	8			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	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		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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	8			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	8			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	8			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	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		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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	8			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	8			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	8			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	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		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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	8			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	8			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	8			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	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		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	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	8			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	7			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	7			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	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					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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	2	1	04	01	H9572_006_2	7			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	7			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	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					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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	3	1	04	01	H9572_006_3	7			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	7			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	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					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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	4	1	04	01	H9572_006_4	7			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	7			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	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					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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	6	1	04	01	H9572_006_6	7			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	7			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	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					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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	1	1	04	01	H9572_007_1	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	7			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	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											50.00	50		50				48.00	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	7			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	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															
H9576	001	0	1	48	05	H9576_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															
H9576	001	0	1	48	05	H9576_001_0	4			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																								
H9615	007	0	1	04	01	H9615_007_0	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H9615	007	0	1	04	01	H9615_007_0	7			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	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																			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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				92.88	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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				411.91	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	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H9615	008	0	1	04	01	H9615_008_0	7			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	008	0	1	04	01	H9615_008_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		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		90.00				35.00		35.00
H9615	008	0	1	04	01	H9615_008_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				99.63	28		28																		28		28															28			28								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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				553.28	28																				28																	28			28								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	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H9615	010	0	1	04	01	H9615_010_0	7			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	010	0	1	04	01	H9615_010_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		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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				112.30	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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				587.96	26																				26																	26			26								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	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H9615	012	0	1	04	01	H9615_012_0	7			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	012	0	1	04	01	H9615_012_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		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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				103.24	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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				900.78	30																				30																	30			30								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	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H9615	015	0	1	04	01	H9615_015_0	7			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	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		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	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				110.17	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	015	0	1	04	01	H9615_015_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				692.14	28																				28																	28			28								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	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H9615	018	0	1	04	01	H9615_018_0	7			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	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		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	018	0	1	04	01	H9615_018_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				99.25	26		26																		26		26															26			26								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	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				497.79	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H9615	020	0	1	04	01	H9615_020_0	7			Preferred Generic	4	01	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										0.00		0.00				0.00		0.00				0.00		0.00
H9615	020	0	1	04	01	H9615_020_0	7			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	20.00		60.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										20.00		60.00				20.00		40.00				20.00		20.00
H9615	020	0	1	04	01	H9615_020_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		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	020	0	1	04	01	H9615_020_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				120.18	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	020	0	1	04	01	H9615_020_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				761.15	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H9630	002	0	1	02	01	H9630_002_0	5			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																								
H9630	002	0	1	02	01	H9630_002_0	5			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																								
H9630	002	0	1	02	01	H9630_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											164.39	25	25	25				164.39	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
H9630	002	0	1	02	01	H9630_002_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											43.82	38	38	38				43.82	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
H9630	002	0	1	02	01	H9630_002_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, Select Care Drugs																								
H9630	002	0	1	02	01	H9630_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	0.00				0.00				0.00			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	02	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					10.00	20.00	30.00											19.00	38.00	57.00				10.00	20.00	0.00				19.00				19.00			0.63	0.33		0.63	0.33	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9630	005	0	1	02	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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9630	005	0	1	02	01	H9630_005_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											135.93	22	22	22				135.93	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
H9630	005	0	1	02	01	H9630_005_0	5			Non-Preferred Drug	3	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	200.00				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
H9630	005	0	1	02	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																								
H9630	005	0	1	02	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	02	01	H9630_008_0	5			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																								
H9630	008	0	1	02	01	H9630_008_0	5			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																								
H9630	008	0	1	02	01	H9630_008_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.13	25	25	25				159.13	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
H9630	008	0	1	02	01	H9630_008_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											48.06	46	46	46				48.06	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
H9630	008	0	1	02	01	H9630_008_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, Select Care Drugs																								
H9630	008	0	1	02	01	H9630_008_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																								
H9678	001	0	1	04	01	H9678_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										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	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	15.00																			15.00	30.00	15.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										15.00	30.00	15.00				15.00	30.00	15.00				15.00		15.00
H9678	001	0	1	04	01	H9678_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	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										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	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.08	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
H9678	001	0	1	04	01	H9678_001_0	7			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
H9686	004	0	1	01	01	H9686_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, 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	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										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	8			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	8			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	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				576.63	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	8			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	005	0	1	01	01	H9686_005_0	8		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				2.91	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
H9686	005	0	1	01	01	H9686_005_0	8		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.47	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9686	005	0	1	01	01	H9686_005_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				84.07	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
H9686	005	0	1	01	01	H9686_005_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				43.57	28	28	28																		28	28	28															28			28								Preferred Generic, Generic, 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	005	0	1	01	01	H9686_005_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				477.70	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9686	005	0	1	01	01	H9686_005_0	8		N	Select Care Drugs	4	01	1	1	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				2.13	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9699	007	0	1	01	01	H9699_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																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9699	007	0	1	01	01	H9699_007_0	5			Generic	4	11	3	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	5.00		12.50																			5.00		0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9699	007	0	1	01	01	H9699_007_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		131.00																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
H9699	007	0	1	01	01	H9699_007_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				72.21	36		36																		36		36															36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00				35.00		35.00
H9699	007	0	1	01	01	H9699_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				82.83	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
H9700	001	0	1	04	01	H9700_001_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9700	001	0	1	04	01	H9700_001_0	7			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
H9700	001	0	1	04	01	H9700_001_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H9700	001	0	1	04	01	H9700_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				46.00	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
H9700	001	0	1	04	01	H9700_001_0	7			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
H9700	002	0	1	04	01	H9700_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9700	002	0	1	04	01	H9700_002_0	7			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
H9700	002	0	1	04	01	H9700_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				59.00	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
H9700	002	0	1	04	01	H9700_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				46.00	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
H9700	002	0	1	04	01	H9700_002_0	7			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
H9700	003	0	1	04	01	H9700_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9700	003	0	1	04	01	H9700_003_0	7			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
H9700	003	0	1	04	01	H9700_003_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H9700	003	0	1	04	01	H9700_003_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				46.00	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
H9700	003	0	1	04	01	H9700_003_0	7			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
H9700	004	0	1	04	01	H9700_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9700	004	0	1	04	01	H9700_004_0	7			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
H9700	004	0	1	04	01	H9700_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	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
H9700	004	0	1	04	01	H9700_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				46.00	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
H9700	004	0	1	04	01	H9700_004_0	7			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
H9700	005	0	1	04	01	H9700_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9700	005	0	1	04	01	H9700_005_0	7			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
H9700	005	0	1	04	01	H9700_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	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
H9700	005	0	1	04	01	H9700_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				46.00	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
H9700	005	0	1	04	01	H9700_005_0	7			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
H9700	006	0	1	04	01	H9700_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9700	006	0	1	04	01	H9700_006_0	7			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
H9700	006	0	1	04	01	H9700_006_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	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
H9700	006	0	1	04	01	H9700_006_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				46.00	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
H9700	006	0	1	04	01	H9700_006_0	7			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
H9706	001	0	1	01	01	H9706_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								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H9706	001	0	1	01	01	H9706_001_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H9706	001	0	1	01	01	H9706_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					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	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											68.50	50	50	50				72.60	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
H9706	001	0	1	01	01	H9706_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											636.40	33						655.39	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9706	005	0	1	01	01	H9706_005_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H9706	005	0	1	01	01	H9706_005_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H9706	005	0	1	01	01	H9706_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	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	005	0	1	01	01	H9706_005_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											98.07	30	30	30				88.87	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	105.00	35.00	70.00	105.00	35.00		35.00
H9706	005	0	1	01	01	H9706_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.47	33						629.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9706	007	0	1	01	01	H9706_007_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H9706	007	0	1	01	01	H9706_007_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H9706	007	0	1	01	01	H9706_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	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	007	0	1	01	01	H9706_007_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											87.06	25	25	25				95.82	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
H9706	007	0	1	01	01	H9706_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											515.96	25						416.93	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9706	008	0	1	01	01	H9706_008_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H9706	008	0	1	01	01	H9706_008_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H9706	008	0	1	01	01	H9706_008_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	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	008	0	1	01	01	H9706_008_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											112.40	25	25	25				79.69	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
H9706	008	0	1	01	01	H9706_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											555.54	33						578.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9706	009	0	1	01	01	H9706_009_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	36.00				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										18.00	36.00	54.00	0.00	0.00	0.00	18.00	36.00	36.00	0.00	0.00	0.00	18.00		18.00
H9706	009	0	1	01	01	H9706_009_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	60.00					10.00	20.00	30.00											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										20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	40.00	10.00	20.00	20.00	20.00		20.00
H9706	009	0	1	01	01	H9706_009_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	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	009	0	1	01	01	H9706_009_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											99.53	26	26	26				87.16	26	26	26										26	26	26				26	26	26			26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											552.02	33						550.95	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9712	001	0	1	48	05	H9712_001_0	9			Generic Drugs	4	11		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	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	9			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	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	4			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
H9725	006	0	1	01	01	H9725_006_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											680.40	33						703.08	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	008	0	1	01	01	H9725_008_0	4			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
H9725	008	0	1	01	01	H9725_008_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	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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	008	0	1	01	01	H9725_008_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											921.20	33						729.94	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
H9725	009	1	1	01	01	H9725_009_1	4			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
H9725	009	1	1	01	01	H9725_009_1	4			Generic	4	11	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
H9725	009	1	1	01	01	H9725_009_1	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											663.02	33						788.57	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
H9725	009	2	1	01	01	H9725_009_2	4			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
H9725	009	2	1	01	01	H9725_009_2	4			Generic	4	11	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
H9725	009	2	1	01	01	H9725_009_2	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											663.02	33						788.57	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
H9725	009	3	1	01	01	H9725_009_3	4			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
H9725	009	3	1	01	01	H9725_009_3	4			Generic	4	11	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
H9725	009	3	1	01	01	H9725_009_3	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											663.02	33						788.57	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
H9725	009	4	1	01	01	H9725_009_4	4			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
H9725	009	4	1	01	01	H9725_009_4	4			Generic	4	11	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
H9725	009	4	1	01	01	H9725_009_4	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											663.02	33						788.57	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
H9725	010	0	1	01	01	H9725_010_0	4			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
H9725	010	0	1	01	01	H9725_010_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					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	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	010	0	1	01	01	H9725_010_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											723.02	33						723.28	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
H9725	014	0	1	01	01	H9725_014_0	4			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
H9725	014	0	1	01	01	H9725_014_0	4			Generic	4	11	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
H9725	014	0	1	01	01	H9725_014_0	4			Preferred Brand	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	4			Non-Preferred Drug	4	11	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	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											726.74	33						670.32	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
H9725	015	1	1	01	01	H9725_015_1	4			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
H9725	015	1	1	01	01	H9725_015_1	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	015	1	1	01	01	H9725_015_1	4			Preferred Brand	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	015	1	1	01	01	H9725_015_1	4			Non-Preferred Drug	4	11	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	015	1	1	01	01	H9725_015_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											553.00	33						659.80	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
H9725	015	2	1	01	01	H9725_015_2	4			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
H9725	015	2	1	01	01	H9725_015_2	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	015	2	1	01	01	H9725_015_2	4			Preferred Brand	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	015	2	1	01	01	H9725_015_2	4			Non-Preferred Drug	4	11	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	015	2	1	01	01	H9725_015_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											553.00	33						659.80	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
H9725	015	3	1	01	01	H9725_015_3	4			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
H9725	015	3	1	01	01	H9725_015_3	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	015	3	1	01	01	H9725_015_3	4			Preferred Brand	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	015	3	1	01	01	H9725_015_3	4			Non-Preferred Drug	4	11	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	015	3	1	01	01	H9725_015_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											553.00	33						659.80	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
H9725	015	4	1	01	01	H9725_015_4	4			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
H9725	015	4	1	01	01	H9725_015_4	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	2	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										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	015	4	1	01	01	H9725_015_4	4			Preferred Brand	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	015	4	1	01	01	H9725_015_4	4			Non-Preferred Drug	4	11	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	015	4	1	01	01	H9725_015_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											553.00	33						659.80	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
H9725	016	0	1	01	01	H9725_016_0	4			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
H9725	016	0	1	01	01	H9725_016_0	4			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					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	016	0	1	01	01	H9725_016_0	4			Preferred Brand	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	016	0	1	01	01	H9725_016_0	4			Non-Preferred Drug	4	11	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	016	0	1	01	01	H9725_016_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											790.69	33						768.89	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
H9730	007	0	1	02	01	H9730_007_0	5			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																								
H9730	007	0	1	02	01	H9730_007_0	5			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																								
H9730	007	0	1	02	01	H9730_007_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											158.18	25	25	25				158.18	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
H9730	007	0	1	02	01	H9730_007_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											39.80	48	48	48				39.80	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
H9730	007	0	1	02	01	H9730_007_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, Select Care Drugs																								
H9730	007	0	1	02	01	H9730_007_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																								
H9730	009	0	1	02	01	H9730_009_0	5			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																								
H9730	009	0	1	02	01	H9730_009_0	5			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																								
H9730	009	0	1	02	01	H9730_009_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.03	25	25	25				159.03	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
H9730	009	0	1	02	01	H9730_009_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											42.29	40	40	40				41.23	39	39	39										40	40	40				39	39	39			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
H9730	009	0	1	02	01	H9730_009_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, Select Care Drugs																								
H9730	009	0	1	02	01	H9730_009_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																								
H9730	010	0	1	02	01	H9730_010_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					12.00	24.00	36.00											19.00	38.00	57.00				12.00	24.00	0.00				19.00				19.00			0.63	0.4		0.63	0.4	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9730	010	0	1	02	01	H9730_010_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9730	010	0	1	02	01	H9730_010_0	5			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											121.89	20	20	20				121.89	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
H9730	010	0	1	02	01	H9730_010_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											30.60	36	36	36				30.60	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
H9730	010	0	1	02	01	H9730_010_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																								
H9730	010	0	1	02	01	H9730_010_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																								
H9763	003	1	1	01	01	H9763_003_1	12			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	12			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	12			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	12			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	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				723.88	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	11			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	11			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	11			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	11			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	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				723.88	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	11			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	11			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	11			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	11			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	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 Brand, Specialty Tier										35.00						35.00						35.00		35.00
H9763	004	2	1	02	01	H9763_004_2	11			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	11			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	11			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	11			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	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 Brand, Specialty Tier										35.00						35.00						35.00		35.00
H9763	005	0	1	01	01	H9763_005_0	11			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	11			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	11			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	11			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	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 Brand, Specialty Tier										35.00						35.00						35.00		35.00
H9808	004	0	1	04	01	H9808_004_0	8			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	25.00					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																								
H9808	004	0	1	04	01	H9808_004_0	8			Generic	4	01	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								20.00	40.00	50.00					5.00	10.00	12.50					5.00	10.00	12.50																	20.00			20.00			0.67	0.17	0.17			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9808	004	0	1	04	01	H9808_004_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	117.50					47.00	94.00	117.50					47.00	94.00	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	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9808	004	0	1	04	01	H9808_004_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	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
H9808	004	0	1	04	01	H9808_004_0	8			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											783.51	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	8			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	8			Generic	4	01	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								12.00	24.00	30.00					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	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	117.50					47.00	94.00	117.50					47.00	94.00	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	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9808	005	0	1	04	01	H9808_005_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	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
H9808	005	0	1	04	01	H9808_005_0	8			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											607.24	33	33	33				809.18	33	33	33				33	33	33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9808	010	0	1	04	01	H9808_010_0	9			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	25.00					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																								
H9808	010	0	1	04	01	H9808_010_0	9			Generic	4	01	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								20.00	40.00	50.00					5.00	10.00	12.50					5.00	10.00	12.50																	20.00			20.00			0.67	0.17	0.17			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9808	010	0	1	04	01	H9808_010_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	117.50					47.00	94.00	117.50					47.00	94.00	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	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9808	010	0	1	04	01	H9808_010_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											97.34	50	50	50				80.85	40	40	40				40	40	40																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
H9808	010	0	1	04	01	H9808_010_0	9			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											721.62	30	30	30				809.18	30	30	30				30	30	30																30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9827	001	0	1	01	01	H9827_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				48.79	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	70.00				35.00		35.00
H9827	001	0	1	01	01	H9827_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				85.48	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
H9827	001	0	1	01	01	H9827_001_0	7			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				66.45	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	70.00				35.00		35.00
H9827	004	0	1	01	01	H9827_004_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				94.98	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
H9827	004	0	1	01	01	H9827_004_0	7			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
H9834	001	0	1	01	01	H9834_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	5.00	10.00	12.50																			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																								
H9834	001	0	1	01	01	H9834_001_0	6			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	37.50																			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, Select Care Drugs																								
H9834	001	0	1	01	01	H9834_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				111.03	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
H9834	001	0	1	01	01	H9834_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				62.54	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H9834	001	0	1	01	01	H9834_001_0	6			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																								
H9834	001	0	1	01	01	H9834_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9834	003	0	1	01	01	H9834_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	5.00	10.00	12.50																			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																								
H9834	003	0	1	01	01	H9834_003_0	6			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	37.50																			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, Select Care Drugs																								
H9834	003	0	1	01	01	H9834_003_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				122.52	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
H9834	003	0	1	01	01	H9834_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				69.01	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H9834	003	0	1	01	01	H9834_003_0	6			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																								
H9834	003	0	1	01	01	H9834_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9834	006	0	1	01	01	H9834_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	5.00	10.00	12.50																			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																								
H9834	006	0	1	01	01	H9834_006_0	6			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	37.50																			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, Select Care Drugs																								
H9834	006	0	1	01	01	H9834_006_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				132.96	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
H9834	006	0	1	01	01	H9834_006_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				73.31	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, 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
H9834	006	0	1	01	01	H9834_006_0	6			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, Select Care Drugs																								
H9834	006	0	1	01	01	H9834_006_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
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															
H9884	008	0	1	04	01	H9884_008_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				56.00	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
H9884	008	0	1	04	01	H9884_008_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				43.00	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
H9884	008	0	1	04	01	H9884_008_0	7			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
H9884	011	0	1	04	01	H9884_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	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	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	011	0	1	04	01	H9884_011_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				34.00	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
H9884	011	0	1	04	01	H9884_011_0	7			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
H9884	013	0	1	04	01	H9884_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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.00	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
H9884	013	0	1	04	01	H9884_013_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				36.00	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
H9884	013	0	1	04	01	H9884_013_0	7			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	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										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	7			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	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				69.00	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
H9888	001	0	1	04	01	H9888_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				37.00	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
H9888	001	0	1	04	01	H9888_001_0	7			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	002	0	1	04	01	H9888_002_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
H9888	002	0	1	04	01	H9888_002_0	8			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	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				69.00	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
H9888	002	0	1	04	01	H9888_002_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				36.00	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
H9888	002	0	1	04	01	H9888_002_0	8			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	005	0	1	04	01	H9888_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										0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9888	005	0	1	04	01	H9888_005_0	7			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
H9888	005	0	1	04	01	H9888_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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
H9888	005	0	1	04	01	H9888_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				45.00	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
H9888	005	0	1	04	01	H9888_005_0	7			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	006	0	1	04	01	H9888_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	006	0	1	04	01	H9888_006_0	7			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
H9888	006	0	1	04	01	H9888_006_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.00	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
H9888	006	0	1	04	01	H9888_006_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				45.00	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
H9888	006	0	1	04	01	H9888_006_0	7			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
H9900	001	0	1	02	01	H9900_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																								
H9900	001	0	1	02	01	H9900_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H9900	001	0	1	02	01	H9900_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											167.97	25	25	25				167.97	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
H9900	001	0	1	02	01	H9900_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											73.19	33	33	33				70.97	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										35.00	70.00	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	02	01	H9900_001_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, Select Care Drugs																								
H9900	001	0	1	02	01	H9900_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																								
H9900	003	0	1	02	01	H9900_003_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								19.00	38.00	57.00					12.00	24.00	36.00											19.00	38.00	57.00				12.00	24.00	0.00				19.00				19.00			0.63	0.4		0.63	0.4	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9900	003	0	1	02	01	H9900_003_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9900	003	0	1	02	01	H9900_003_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											112.05	19	19	19				112.05	19	19	19										19	19	19				19	19	19			19			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	70.00	105.00	35.00		35.00
H9900	003	0	1	02	01	H9900_003_0	6		N	Non-Preferred Drug	3	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	200.00				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
H9900	003	0	1	02	01	H9900_003_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, Select Care Drugs																								
H9900	003	0	1	02	01	H9900_003_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	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	02	01	H9900_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9900	005	0	1	02	01	H9900_005_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																								
H9900	005	0	1	02	01	H9900_005_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											159.24	25	25	25				159.24	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
H9900	005	0	1	02	01	H9900_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											45.97	36	36	36				44.69	35	35	35										36	36	36				35	35	35			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
H9900	005	0	1	02	01	H9900_005_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, Select Care Drugs																								
H9900	005	0	1	02	01	H9900_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																								
H9900	006	0	1	02	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					12.00	24.00	36.00											19.00	38.00	57.00				12.00	24.00	0.00				19.00				19.00			0.63	0.4		0.63	0.4	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9900	006	0	1	02	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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9900	006	0	1	02	01	H9900_006_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											142.57	22	22	22				142.57	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
H9900	006	0	1	02	01	H9900_006_0	6			Non-Preferred Drug	3	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	200.00				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
H9900	006	0	1	02	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																								
H9900	006	0	1	02	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	009	0	1	02	01	H9900_009_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								19.00	38.00	57.00					18.00	36.00	54.00											19.00	38.00	57.00				18.00	36.00	0.00				19.00				19.00			0.63	0.6		0.63	0.6	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9900	009	0	1	02	01	H9900_009_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					19.00	38.00	57.00											20.00	40.00	60.00				19.00	38.00	0.00				20.00				20.00			0.67	0.63		0.67	0.63	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
H9900	009	0	1	02	01	H9900_009_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											115.85	19	19	19				115.85	19	19	19										19	19	19				19	19	19			19			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	70.00	105.00	35.00		35.00
H9900	009	0	1	02	01	H9900_009_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											31.76	36	36	36				31.76	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
H9900	009	0	1	02	01	H9900_009_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, Select Care Drugs																								
H9900	009	0	1	02	01	H9900_009_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	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	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																								
H9904	001	0	1	04	01	H9904_001_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9904	001	0	1	04	01	H9904_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	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	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				90.63	50	50	50																		50	50	50															50			50								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			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				489.60	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9904	002	0	1	04	01	H9904_002_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	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	002	0	1	04	01	H9904_002_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	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	002	0	1	04	01	H9904_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	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	002	0	1	04	01	H9904_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				93.09	50	50	50																		50	50	50															50			50								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	002	0	1	04	01	H9904_002_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				466.54	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
H9907	001	0	1	04	01	H9907_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								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										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	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										20.00	40.00	60.00	8.00	16.00	24.00	8.00	16.00	16.00				20.00		8.00
H9907	001	0	1	04	01	H9907_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											65.01	23	23	23				64.55	23	23	23				23	23	23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	8			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				45.97	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines										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	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																								
H9907	001	0	1	04	01	H9907_001_0	8			Vaccines	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																								
H9917	001	0	1	01	01	H9917_001_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																								
H9917	001	0	1	01	01	H9917_001_0	8			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	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										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	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										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	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																								
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										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			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	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																								
H9917	004	0	1	01	01	H9917_004_0	7			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	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
H9917	004	0	1	01	01	H9917_004_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
H9917	004	0	1	01	01	H9917_004_0	7			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	005	0	1	01	01	H9917_005_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																								
H9917	005	0	1	01	01	H9917_005_0	7			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	005	0	1	01	01	H9917_005_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
H9917	005	0	1	01	01	H9917_005_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
H9917	005	0	1	01	01	H9917_005_0	7			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																								
R0110	003	0	1	31	11	R0110_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																									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	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
R0110	003	0	1	31	11	R0110_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		95.00	35.00		35.00
R0110	003	0	1	31	11	R0110_003_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
R0110	003	0	1	31	11	R0110_003_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
R0110	005	0	1	31	11	R0110_005_0	4			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
R0110	005	0	1	31	11	R0110_005_0	4			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
R0110	005	0	1	31	11	R0110_005_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		95.00	35.00		35.00
R0110	005	0	1	31	11	R0110_005_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				83.00	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
R0110	005	0	1	31	11	R0110_005_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
R0110	008	0	1	31	11	R0110_008_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
R0110	008	0	1	31	11	R0110_008_0	4			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
R0110	008	0	1	31	11	R0110_008_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		95.00	35.00		35.00
R0110	008	0	1	31	11	R0110_008_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				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		35.00
R0110	008	0	1	31	11	R0110_008_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
R0110	012	0	1	31	11	R0110_012_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
R0110	012	0	1	31	11	R0110_012_0	4			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
R0110	012	0	1	31	11	R0110_012_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		95.00	35.00		35.00
R0110	012	0	1	31	11	R0110_012_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				84.00	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
R0110	012	0	1	31	11	R0110_012_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
R0110	018	0	1	31	11	R0110_018_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
R0110	018	0	1	31	11	R0110_018_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
R0110	018	0	1	31	11	R0110_018_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		95.00	35.00		35.00
R0110	018	0	1	31	11	R0110_018_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	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		35.00
R0110	018	0	1	31	11	R0110_018_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
R0110	020	0	1	31	11	R0110_020_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
R0110	020	0	1	31	11	R0110_020_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
R0110	020	0	1	31	11	R0110_020_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		95.00	35.00		35.00
R0110	020	0	1	31	11	R0110_020_0	4			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
R0110	020	0	1	31	11	R0110_020_0	4			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
R0759	001	0	1	31	11	R0759_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																								
R0759	001	0	1	31	11	R0759_001_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																								
R0759	001	0	1	31	11	R0759_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
R0759	001	0	1	31	11	R0759_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	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	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				165.00	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
R1532	002	0	1	31	11	R1532_002_0	5			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		90				1	2				30		90	30		31				1.00	24		24																								24		24				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
R1532	002	0	1	31	11	R1532_002_0	5			Generic	4	11	1	1	2	1	110		01		110	1	30		90				2	2				30		90	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
R1532	002	0	1	31	11	R1532_002_0	5			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				61.00	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	5			Non-Preferred Drug	4	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
R1532	002	0	1	31	11	R1532_002_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
R2604	001	0	1	31	11	R2604_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																								
R2604	001	0	1	31	11	R2604_001_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																								
R2604	001	0	1	31	11	R2604_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
R2604	001	0	1	31	11	R2604_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	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	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				166.00	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
R2604	003	0	1	31	11	R2604_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																								
R2604	003	0	1	31	11	R2604_003_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																								
R2604	003	0	1	31	11	R2604_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										25.00		75.00						75.00			65.00	25.00		25.00
R2604	003	0	1	31	11	R2604_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
R2604	003	0	1	31	11	R2604_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				166.00	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
R3444	009	0	1	31	11	R3444_009_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																								
R3444	009	0	1	31	11	R3444_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																								
R3444	009	0	1	31	11	R3444_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										25.00		75.00						75.00			65.00	25.00		25.00
R3444	009	0	1	31	11	R3444_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	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	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				158.00	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
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		12.00																											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			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	20.00		60.00																											60.00						0.00				20.00				20.00		0.66						0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				144.00	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
R3444	024	0	1	31	11	R3444_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																								
R3444	024	0	1	31	11	R3444_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																								
R3444	024	0	1	31	11	R3444_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
R3444	024	0	1	31	11	R3444_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
R3444	024	0	1	31	11	R3444_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				146.00	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
R4182	003	0	1	31	11	R4182_003_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
R4182	003	0	1	31	11	R4182_003_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
R4182	003	0	1	31	11	R4182_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		95.00	35.00		35.00
R4182	003	0	1	31	11	R4182_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
R4182	003	0	1	31	11	R4182_003_0	4			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
R4182	004	0	1	31	11	R4182_004_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
R4182	004	0	1	31	11	R4182_004_0	4			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	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		95.00	35.00		35.00
R4182	004	0	1	31	11	R4182_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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		35.00
R4182	004	0	1	31	11	R4182_004_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
R4487	001	0	1	31	11	R4487_001_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																								
R4487	001	0	1	31	11	R4487_001_0	9			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																								
R4487	001	0	1	31	11	R4487_001_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											41.57	20	20	20				41.57	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	70.00				35.00		35.00
R4487	001	0	1	31	11	R4487_001_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											36.27	35	35	35				36.27	35	35	35				35	35	35															35			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
R4487	001	0	1	31	11	R4487_001_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																								
R4487	001	0	1	31	11	R4487_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
R5342	005	0	1	31	11	R5342_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																								
R5342	005	0	1	31	11	R5342_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																								
R5342	005	0	1	31	11	R5342_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
R5342	005	0	1	31	11	R5342_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
R5342	005	0	1	31	11	R5342_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				172.00	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
R5361	002	0	1	31	11	R5361_002_0	5			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		90				1	2				30		90	30		31				1.00	24		24																								24		24				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
R5361	002	0	1	31	11	R5361_002_0	5			Generic	4	11	1	1	2	1	110		01		110	1	30		90				2	2				30		90	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
R5361	002	0	1	31	11	R5361_002_0	5			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				68.00	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			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				49.00	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
R5361	002	0	1	31	11	R5361_002_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
R5826	005	0	1	31	11	R5826_005_0	4			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
R5826	005	0	1	31	11	R5826_005_0	4			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
R5826	005	0	1	31	11	R5826_005_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		95.00	35.00		35.00
R5826	005	0	1	31	11	R5826_005_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				89.00	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
R5826	005	0	1	31	11	R5826_005_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
R5826	074	0	1	31	11	R5826_074_0	4			Preferred Generic	4	11	3	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
R5826	074	0	1	31	11	R5826_074_0	4			Generic	4	11	3	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
R5826	074	0	1	31	11	R5826_074_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		95.00	35.00		35.00
R5826	074	0	1	31	11	R5826_074_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	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		35.00
R5826	074	0	1	31	11	R5826_074_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
R5941	014	0	1	31	11	R5941_014_0	9			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																								
R5941	014	0	1	31	11	R5941_014_0	9			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																								
R5941	014	0	1	31	11	R5941_014_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.52	25	25	25				51.61	20	20	20				20	20	20															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	70.00				35.00		35.00
R5941	014	0	1	31	11	R5941_014_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											42.92	35	35	35				42.92	35	35	35				35	35	35															35			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
R5941	014	0	1	31	11	R5941_014_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																								
R5941	014	0	1	31	11	R5941_014_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																								
R6694	003	0	1	31	11	R6694_003_0	5			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
R6694	003	0	1	31	11	R6694_003_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	10.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
R6694	003	0	1	31	11	R6694_003_0	5			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.45	25	25	25				84.42	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
R6694	003	0	1	31	11	R6694_003_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											34.62	35	35	35				29.74	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
R6694	003	0	1	31	11	R6694_003_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1057.97	33						1266.72	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
R6694	006	0	1	31	11	R6694_006_0	3			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
R6694	006	0	1	31	11	R6694_006_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	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																								
R6694	006	0	1	31	11	R6694_006_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.99	24	24	24				115.19	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
R6694	006	0	1	31	11	R6694_006_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.48	25	25	25				42.07	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
R6694	006	0	1	31	11	R6694_006_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											836.73	25						795.19	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
R6801	009	0	1	31	11	R6801_009_0	9			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	9			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																								
R6801	009	0	1	31	11	R6801_009_0	9			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		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	9			Non-Preferred Drug	4	11	1	2	4	1	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			35.00		35.00
R6801	009	0	1	31	11	R6801_009_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				162.00	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
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	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	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	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																								
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	010		01		010	1	30						2	2				30			30		31	100.00																											100.00						100.00						100.00				100.00		3.33				3.33	3.33	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00			35.00			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				168.00	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
R7220	002	0	1	31	11	R7220_002_0	4			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				1.00	24		24																								25		25				24		0			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										34.00		102.00				34.00		102.00	34.00		0.00	34.00		34.00
R7220	002	0	1	31	11	R7220_002_0	4			Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				2.00	25		25																								25		25				25		0			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00				35.00		105.00	35.00		0.00	35.00		35.00
R7220	002	0	1	31	11	R7220_002_0	4			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				60.00	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			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	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	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
S1030	001	0		29	10	S1030_001_0	1			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	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		100	1	2				30		100	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		100	1	2				30		100	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		100	1	2				30		100	30		31											77.20	50		50				57.84	45		45										50		50				45		45			50			50								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		100	1	2				30		100	30		31											504.22	33		33				497.77	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		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										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		100				1	2	30		100				30		31	4.00		12.00																			4.00		8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										4.00		12.00				4.00		8.00				4.00		4.00
S1030	006	0		29	10	S1030_006_0	1			Preferred Brand	2	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				57.45	24		24																		24		24															24			24								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		100				1	2	30		100				30		31				63.63	39		39																		39		39															39			39								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		100				1	2	30		100				30		31				353.19	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S2468	003	0		29	10	S2468_003_0	2			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					3.00	6.00	7.50							7.50																9.00				9.00			0.30	0.10				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S2468	003	0		29	10	S2468_003_0	2			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	35.00							35.00																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	2			Preferred Brand	3	11	1	1	3	1		111	01	100		1				30	60	90	2	2			90				30		31											56.74	20	20	20				54.58	18	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			105.00				35.00		35.00
S2468	003	0		29	10	S2468_003_0	2			Non-Preferred Drug	3	11	1	1	4	1		111	01	100		1				30	60	90	2	2			90				30		31											83.50	50	50	50				49.01	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	2			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											602.57	25						402.38	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S2468	004	0		29	10	S2468_004_0	2			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	2			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	2			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	129.00							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	105.00			86.00				35.00		35.00
S2468	004	0		29	10	S2468_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	2	2			90				30		31											90.79	50	50	50				64.86	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	2			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											780.16	33						432.53	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S2893	001	0		29	10	S2893_001_0	2			Preferred Generic	3	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	001	0		29	10	S2893_001_0	2			Generic	3	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					5.00	10.00	10.00																10.00				10.00			0.33	0.17	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	5.00	10.00	10.00				10.00		10.00
S2893	001	0		29	10	S2893_001_0	2			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											57.80	25	25	25				51.00	22	22	22				22	22	22															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
S2893	001	0		29	10	S2893_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											55.79	35	35	35				53.76	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	70.00				35.00		35.00
S2893	001	0		29	10	S2893_001_0	2			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
S2893	003	0		29	10	S2893_003_0	2			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	2			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	2			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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											59.34	44	44	44				45.60	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	2			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							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	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	012	0		29	10	S4802_012_0	2			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																								
S4802	012	0		29	10	S4802_012_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											42.94	22	22	22				40.99	21	21	21										22	22	22				21	21	21			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											35.06	35	35	35				35.06	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
S4802	012	0		29	10	S4802_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																								
S4802	013	0		29	10	S4802_013_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	013	0		29	10	S4802_013_0	2			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																								
S4802	013	0		29	10	S4802_013_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.67	22	22	22				45.67	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.65	36	36	36				39.52	35	35	35										36	36	36				35	35	35			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
S4802	013	0		29	10	S4802_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																								
S4802	014	0		29	10	S4802_014_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	014	0		29	10	S4802_014_0	2			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																								
S4802	014	0		29	10	S4802_014_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.27	22	22	22				45.12	21	21	21										22	22	22				21	21	21			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.44	36	36	36				36.40	35	35	35										36	36	36				35	35	35			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
S4802	014	0		29	10	S4802_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																								
S4802	020	0		29	10	S4802_020_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	020	0		29	10	S4802_020_0	2			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																								
S4802	020	0		29	10	S4802_020_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.53	22	22	22				45.53	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.57	36	36	36				40.57	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
S4802	020	0		29	10	S4802_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																								
S4802	021	0		29	10	S4802_021_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	021	0		29	10	S4802_021_0	2			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																								
S4802	021	0		29	10	S4802_021_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.24	21	21	21				45.24	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.89	36	36	36				40.89	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
S4802	021	0		29	10	S4802_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																								
S4802	069	0		29	10	S4802_069_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	069	0		29	10	S4802_069_0	2			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																								
S4802	069	0		29	10	S4802_069_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.60	22	22	22				46.60	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											42.90	36	36	36				42.90	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
S4802	069	0		29	10	S4802_069_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																								
S4802	070	0		29	10	S4802_070_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	070	0		29	10	S4802_070_0	2			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																								
S4802	070	0		29	10	S4802_070_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.42	22	22	22				46.42	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.55	36	36	36				37.55	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
S4802	070	0		29	10	S4802_070_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																								
S4802	071	0		29	10	S4802_071_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	071	0		29	10	S4802_071_0	2			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																								
S4802	071	0		29	10	S4802_071_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.86	22	22	22				42.82	21	21	21										22	22	22				21	21	21			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											34.13	35	35	35				34.13	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
S4802	071	0		29	10	S4802_071_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																								
S4802	072	0		29	10	S4802_072_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	072	0		29	10	S4802_072_0	2			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																								
S4802	072	0		29	10	S4802_072_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.81	21	21	21				37.92	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
S4802	072	0		29	10	S4802_072_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											39.78	36	36	36				39.78	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
S4802	072	0		29	10	S4802_072_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																								
S4802	073	0		29	10	S4802_073_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	073	0		29	10	S4802_073_0	2			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																								
S4802	073	0		29	10	S4802_073_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.73	21	21	21				37.84	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
S4802	073	0		29	10	S4802_073_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											34.05	35	35	35				34.05	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
S4802	073	0		29	10	S4802_073_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																								
S4802	074	0		29	10	S4802_074_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	074	0		29	10	S4802_074_0	2			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																								
S4802	074	0		29	10	S4802_074_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.06	22	22	22				46.06	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.00	35	35	35				32.00	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
S4802	074	0		29	10	S4802_074_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																								
S4802	075	0		29	10	S4802_075_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	075	0		29	10	S4802_075_0	2			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																								
S4802	075	0		29	10	S4802_075_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.86	21	21	21				41.86	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.05	36	36	36				43.80	35	35	35										36	36	36				35	35	35			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
S4802	075	0		29	10	S4802_075_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																								
S4802	076	0		29	10	S4802_076_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	076	0		29	10	S4802_076_0	2			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																								
S4802	076	0		29	10	S4802_076_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.81	22	22	22				46.81	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.64	37	37	37				43.43	36	36	36										37	37	37				36	36	36			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
S4802	076	0		29	10	S4802_076_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																								
S4802	077	0		29	10	S4802_077_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	077	0		29	10	S4802_077_0	2			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																								
S4802	077	0		29	10	S4802_077_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.61	21	21	21				46.61	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.51	36	36	36				51.05	35	35	35										36	36	36				35	35	35			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
S4802	077	0		29	10	S4802_077_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																								
S4802	078	0		29	10	S4802_078_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	078	0		29	10	S4802_078_0	2			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																								
S4802	078	0		29	10	S4802_078_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.20	21	21	21				43.20	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.78	36	36	36				46.45	35	35	35										36	36	36				35	35	35			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
S4802	078	0		29	10	S4802_078_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																								
S4802	079	0		29	10	S4802_079_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	079	0		29	10	S4802_079_0	2			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																								
S4802	079	0		29	10	S4802_079_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.33	23	23	23				47.19	22	22	22										23	23	23				22	22	22			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
S4802	079	0		29	10	S4802_079_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											41.08	35	35	35				41.08	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
S4802	079	0		29	10	S4802_079_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																								
S4802	080	0		29	10	S4802_080_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	080	0		29	10	S4802_080_0	2			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																								
S4802	080	0		29	10	S4802_080_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.77	21	21	21				41.77	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											42.68	37	37	37				41.53	36	36	36										37	37	37				36	36	36			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
S4802	080	0		29	10	S4802_080_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																								
S4802	081	0		29	10	S4802_081_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	081	0		29	10	S4802_081_0	2			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																								
S4802	081	0		29	10	S4802_081_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.66	22	22	22				44.54	21	21	21										22	22	22				21	21	21			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.90	36	36	36				39.77	35	35	35										36	36	36				35	35	35			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
S4802	081	0		29	10	S4802_081_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																								
S4802	082	0		29	10	S4802_082_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	082	0		29	10	S4802_082_0	2			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																								
S4802	082	0		29	10	S4802_082_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.31	22	22	22				44.31	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.30	36	36	36				37.30	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
S4802	082	0		29	10	S4802_082_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																								
S4802	083	0		29	10	S4802_083_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	083	0		29	10	S4802_083_0	2			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																								
S4802	083	0		29	10	S4802_083_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.99	22	22	22				39.99	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.22	36	36	36				39.10	35	35	35										36	36	36				35	35	35			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
S4802	083	0		29	10	S4802_083_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																								
S4802	084	0		29	10	S4802_084_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	084	0		29	10	S4802_084_0	2			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																								
S4802	084	0		29	10	S4802_084_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											42.66	21	21	21				42.66	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.99	36	36	36				36.93	35	35	35										36	36	36				35	35	35			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
S4802	084	0		29	10	S4802_084_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																								
S4802	085	0		29	10	S4802_085_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	085	0		29	10	S4802_085_0	2			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																								
S4802	085	0		29	10	S4802_085_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.63	22	22	22				42.60	21	21	21										22	22	22				21	21	21			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.67	36	36	36				39.54	35	35	35										36	36	36				35	35	35			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
S4802	085	0		29	10	S4802_085_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																								
S4802	086	0		29	10	S4802_086_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	086	0		29	10	S4802_086_0	2			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																								
S4802	086	0		29	10	S4802_086_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.94	21	21	21				43.94	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.69	37	37	37				38.62	36	36	36										37	37	37				36	36	36			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
S4802	086	0		29	10	S4802_086_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																								
S4802	087	0		29	10	S4802_087_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	087	0		29	10	S4802_087_0	2			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																								
S4802	087	0		29	10	S4802_087_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.52	23	23	23				50.52	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
S4802	087	0		29	10	S4802_087_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											38.77	36	36	36				37.70	35	35	35										36	36	36				35	35	35			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
S4802	087	0		29	10	S4802_087_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																								
S4802	088	0		29	10	S4802_088_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	088	0		29	10	S4802_088_0	2			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																								
S4802	088	0		29	10	S4802_088_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.44	21	21	21				43.44	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.23	35	35	35				38.23	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
S4802	088	0		29	10	S4802_088_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																								
S4802	089	0		29	10	S4802_089_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	089	0		29	10	S4802_089_0	2			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																								
S4802	089	0		29	10	S4802_089_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.07	21	21	21				40.07	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	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.37	36	36	36				40.22	35	35	35										36	36	36				35	35	35			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
S4802	089	0		29	10	S4802_089_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																								
S4802	090	0		29	10	S4802_090_0	4			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																								
S4802	090	0		29	10	S4802_090_0	4			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																								
S4802	090	0		29	10	S4802_090_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.93	23	23	23				45.85	22	22	22										23	23	23				22	22	22			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
S4802	090	0		29	10	S4802_090_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											38.12	36	36	36				38.12	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
S4802	090	0		29	10	S4802_090_0	4			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																								
S4802	091	0		29	10	S4802_091_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	091	0		29	10	S4802_091_0	2			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																								
S4802	091	0		29	10	S4802_091_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.09	22	22	22				47.09	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.37	36	36	36				45.08	35	35	35										36	36	36				35	35	35			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
S4802	091	0		29	10	S4802_091_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																								
S4802	092	0		29	10	S4802_092_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	092	0		29	10	S4802_092_0	2			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																								
S4802	092	0		29	10	S4802_092_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											56.77	24	24	24				54.40	23	23	23										24	24	24				23	23	23			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
S4802	092	0		29	10	S4802_092_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											41.15	37	37	37				41.15	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
S4802	092	0		29	10	S4802_092_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																								
S4802	093	0		29	10	S4802_093_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	093	0		29	10	S4802_093_0	2			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																								
S4802	093	0		29	10	S4802_093_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.01	22	22	22				41.06	21	21	21										22	22	22				21	21	21			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.55	36	36	36				38.45	35	35	35										36	36	36				35	35	35			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
S4802	093	0		29	10	S4802_093_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																								
S4802	094	0		29	10	S4802_094_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	094	0		29	10	S4802_094_0	2			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																								
S4802	094	0		29	10	S4802_094_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.63	22	22	22				48.33	21	21	21										22	22	22				21	21	21			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.84	36	36	36				45.54	35	35	35										36	36	36				35	35	35			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
S4802	094	0		29	10	S4802_094_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																								
S4802	095	0		29	10	S4802_095_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	095	0		29	10	S4802_095_0	2			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																								
S4802	095	0		29	10	S4802_095_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.58	23	23	23				53.58	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
S4802	095	0		29	10	S4802_095_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											53.14	36	36	36				51.66	35	35	35										36	36	36				35	35	35			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
S4802	095	0		29	10	S4802_095_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																								
S4802	096	0		29	10	S4802_096_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	096	0		29	10	S4802_096_0	2			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																								
S4802	096	0		29	10	S4802_096_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.91	23	23	23				66.91	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
S4802	096	0		29	10	S4802_096_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											63.60	49	49	49				63.60	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
S4802	096	0		29	10	S4802_096_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																								
S4802	097	0		29	10	S4802_097_0	2			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			0.1	0.00		0.1	0.00	0.1	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	097	0		29	10	S4802_097_0	2			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																								
S4802	097	0		29	10	S4802_097_0	2			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.93	21	21	21				37.08	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
S4802	097	0		29	10	S4802_097_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											42.83	35	35	35				42.83	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
S4802	097	0		29	10	S4802_097_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																								
S4802	132	0		29	10	S4802_132_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	132	0		29	10	S4802_132_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	132	0		29	10	S4802_132_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											168.83	25	25	25				168.83	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
S4802	132	0		29	10	S4802_132_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											55.72	44	44	44				54.45	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
S4802	132	0		29	10	S4802_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																								
S4802	133	0		29	10	S4802_133_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	133	0		29	10	S4802_133_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	133	0		29	10	S4802_133_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											166.42	25	25	25				166.42	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
S4802	133	0		29	10	S4802_133_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											29.36	37	37	37				28.57	36	36	36										37	37	37				36	36	36			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
S4802	133	0		29	10	S4802_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																								
S4802	134	0		29	10	S4802_134_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	134	0		29	10	S4802_134_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	134	0		29	10	S4802_134_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											170.70	25	25	25				170.70	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
S4802	134	0		29	10	S4802_134_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											48.95	41	41	41				47.76	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
S4802	134	0		29	10	S4802_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																								
S4802	135	0		29	10	S4802_135_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	135	0		29	10	S4802_135_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	135	0		29	10	S4802_135_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											171.15	25	25	25				171.15	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
S4802	135	0		29	10	S4802_135_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											46.78	43	43	43				45.69	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
S4802	135	0		29	10	S4802_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																								
S4802	136	0		29	10	S4802_136_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	136	0		29	10	S4802_136_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	136	0		29	10	S4802_136_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											164.31	25	25	25				164.31	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	105.00	35.00	70.00	105.00	35.00		35.00
S4802	136	0		29	10	S4802_136_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											49.50	42	42	42				48.33	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
S4802	136	0		29	10	S4802_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																								
S4802	137	0		29	10	S4802_137_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	137	0		29	10	S4802_137_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	137	0		29	10	S4802_137_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											169.08	25	25	25				169.08	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
S4802	137	0		29	10	S4802_137_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											49.12	42	42	42				47.95	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
S4802	137	0		29	10	S4802_137_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																								
S4802	138	0		29	10	S4802_138_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	138	0		29	10	S4802_138_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	138	0		29	10	S4802_138_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											166.70	25	25	25				166.70	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
S4802	138	0		29	10	S4802_138_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											46.13	35	35	35				44.82	34	34	34										35	35	35				34	34	34			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
S4802	138	0		29	10	S4802_138_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																								
S4802	139	0		29	10	S4802_139_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	139	0		29	10	S4802_139_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	139	0		29	10	S4802_139_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											168.21	25	25	25				168.21	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
S4802	139	0		29	10	S4802_139_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											47.65	38	38	38				46.39	37	37	37										38	38	38				37	37	37			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
S4802	139	0		29	10	S4802_139_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																								
S4802	140	0		29	10	S4802_140_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	140	0		29	10	S4802_140_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	140	0		29	10	S4802_140_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											171.38	25	25	25				171.38	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
S4802	140	0		29	10	S4802_140_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											43.78	42	42	42				42.74	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
S4802	140	0		29	10	S4802_140_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																								
S4802	141	0		29	10	S4802_141_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	141	0		29	10	S4802_141_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	141	0		29	10	S4802_141_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											163.10	25	25	25				163.10	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
S4802	141	0		29	10	S4802_141_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											44.94	42	42	42				44.94	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
S4802	141	0		29	10	S4802_141_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																								
S4802	142	0		29	10	S4802_142_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	142	0		29	10	S4802_142_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	142	0		29	10	S4802_142_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											171.96	25	25	25				171.96	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
S4802	142	0		29	10	S4802_142_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											44.86	43	43	43				43.81	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
S4802	142	0		29	10	S4802_142_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																								
S4802	143	0		29	10	S4802_143_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	143	0		29	10	S4802_143_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	143	0		29	10	S4802_143_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											168.55	25	25	25				168.55	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
S4802	143	0		29	10	S4802_143_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											37.05	39	39	39				37.05	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
S4802	143	0		29	10	S4802_143_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																								
S4802	144	0		29	10	S4802_144_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	144	0		29	10	S4802_144_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	144	0		29	10	S4802_144_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											164.22	25	25	25				164.22	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
S4802	144	0		29	10	S4802_144_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											38.73	38	38	38				37.71	37	37	37										38	38	38				37	37	37			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
S4802	144	0		29	10	S4802_144_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																								
S4802	145	0		29	10	S4802_145_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	145	0		29	10	S4802_145_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	145	0		29	10	S4802_145_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											165.11	25	25	25				165.11	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
S4802	145	0		29	10	S4802_145_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											35.30	38	38	38				35.30	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
S4802	145	0		29	10	S4802_145_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																								
S4802	146	0		29	10	S4802_146_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	146	0		29	10	S4802_146_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	146	0		29	10	S4802_146_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											169.56	25	25	25				169.56	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
S4802	146	0		29	10	S4802_146_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											44.25	38	38	38				44.25	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
S4802	146	0		29	10	S4802_146_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																								
S4802	147	0		29	10	S4802_147_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	147	0		29	10	S4802_147_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	147	0		29	10	S4802_147_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											164.97	25	25	25				164.97	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
S4802	147	0		29	10	S4802_147_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											33.80	39	39	39				32.93	38	38	38										39	39	39				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	70.00	105.00	35.00		35.00
S4802	147	0		29	10	S4802_147_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																								
S4802	148	0		29	10	S4802_148_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	148	0		29	10	S4802_148_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	148	0		29	10	S4802_148_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											168.88	25	25	25				168.88	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
S4802	148	0		29	10	S4802_148_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											49.73	46	46	46				48.65	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
S4802	148	0		29	10	S4802_148_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																								
S4802	149	0		29	10	S4802_149_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	149	0		29	10	S4802_149_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	149	0		29	10	S4802_149_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											165.95	25	25	25				165.95	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
S4802	149	0		29	10	S4802_149_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											51.47	46	46	46				50.35	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
S4802	149	0		29	10	S4802_149_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																								
S4802	150	0		29	10	S4802_150_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	150	0		29	10	S4802_150_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	150	0		29	10	S4802_150_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											163.57	25	25	25				163.57	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
S4802	150	0		29	10	S4802_150_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											38.64	42	42	42				37.72	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
S4802	150	0		29	10	S4802_150_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																								
S4802	151	0		29	10	S4802_151_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	151	0		29	10	S4802_151_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	151	0		29	10	S4802_151_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											161.63	25	25	25				161.63	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
S4802	151	0		29	10	S4802_151_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											50.80	46	46	46				49.69	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
S4802	151	0		29	10	S4802_151_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																								
S4802	152	0		29	10	S4802_152_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	152	0		29	10	S4802_152_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	152	0		29	10	S4802_152_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											164.86	25	25	25				164.86	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
S4802	152	0		29	10	S4802_152_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											35.92	41	41	41				35.05	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
S4802	152	0		29	10	S4802_152_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																								
S4802	153	0		29	10	S4802_153_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	153	0		29	10	S4802_153_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	153	0		29	10	S4802_153_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											165.91	25	25	25				165.91	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
S4802	153	0		29	10	S4802_153_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											31.06	40	40	40				31.06	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
S4802	153	0		29	10	S4802_153_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																								
S4802	154	0		29	10	S4802_154_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	154	0		29	10	S4802_154_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	154	0		29	10	S4802_154_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											163.18	25	25	25				163.18	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
S4802	154	0		29	10	S4802_154_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											28.87	39	39	39				28.13	38	38	38										39	39	39				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	70.00	105.00	35.00		35.00
S4802	154	0		29	10	S4802_154_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																								
S4802	155	0		29	10	S4802_155_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	155	0		29	10	S4802_155_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	155	0		29	10	S4802_155_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											169.06	25	25	25				169.06	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
S4802	155	0		29	10	S4802_155_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											36.32	37	37	37				35.33	36	36	36										37	37	37				36	36	36			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
S4802	155	0		29	10	S4802_155_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																								
S4802	156	0		29	10	S4802_156_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	156	0		29	10	S4802_156_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	156	0		29	10	S4802_156_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											169.62	25	25	25				169.62	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
S4802	156	0		29	10	S4802_156_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											32.83	38	38	38				31.96	37	37	37										38	38	38				37	37	37			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
S4802	156	0		29	10	S4802_156_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																								
S4802	157	0		29	10	S4802_157_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	157	0		29	10	S4802_157_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	157	0		29	10	S4802_157_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											165.76	25	25	25				165.76	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
S4802	157	0		29	10	S4802_157_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											39.66	42	42	42				38.72	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
S4802	157	0		29	10	S4802_157_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																								
S4802	158	0		29	10	S4802_158_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	158	0		29	10	S4802_158_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	158	0		29	10	S4802_158_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											155.73	25	25	25				155.73	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
S4802	158	0		29	10	S4802_158_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											47.87	50	50	50				46.91	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
S4802	158	0		29	10	S4802_158_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																								
S4802	159	0		29	10	S4802_159_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	159	0		29	10	S4802_159_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	159	0		29	10	S4802_159_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											171.49	25	25	25				171.49	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
S4802	159	0		29	10	S4802_159_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											47.95	43	43	43				46.84	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
S4802	159	0		29	10	S4802_159_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																								
S4802	160	0		29	10	S4802_160_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	160	0		29	10	S4802_160_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	160	0		29	10	S4802_160_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											167.19	25	25	25				167.19	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
S4802	160	0		29	10	S4802_160_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											52.00	41	41	41				50.73	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
S4802	160	0		29	10	S4802_160_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																								
S4802	161	0		29	10	S4802_161_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	161	0		29	10	S4802_161_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	161	0		29	10	S4802_161_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											170.12	25	25	25				170.12	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
S4802	161	0		29	10	S4802_161_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											45.03	40	40	40				43.91	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
S4802	161	0		29	10	S4802_161_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																								
S4802	162	0		29	10	S4802_162_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	162	0		29	10	S4802_162_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	162	0		29	10	S4802_162_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											168.47	25	25	25				168.47	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
S4802	162	0		29	10	S4802_162_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											41.52	43	43	43				40.56	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
S4802	162	0		29	10	S4802_162_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																								
S4802	163	0		29	10	S4802_163_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	163	0		29	10	S4802_163_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	163	0		29	10	S4802_163_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											171.60	25	25	25				171.60	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
S4802	163	0		29	10	S4802_163_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											41.23	36	36	36				40.08	35	35	35										36	36	36				35	35	35			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
S4802	163	0		29	10	S4802_163_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																								
S4802	164	0		29	10	S4802_164_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	164	0		29	10	S4802_164_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	164	0		29	10	S4802_164_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											171.79	25	25	25				171.79	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
S4802	164	0		29	10	S4802_164_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											48.35	38	38	38				47.08	37	37	37										38	38	38				37	37	37			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
S4802	164	0		29	10	S4802_164_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																								
S4802	165	0		29	10	S4802_165_0	2			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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	165	0		29	10	S4802_165_0	2			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.5	0.17		0.5	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S4802	165	0		29	10	S4802_165_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											161.94	25	25	25				161.94	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
S4802	165	0		29	10	S4802_165_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											41.69	36	36	36				40.53	35	35	35										36	36	36				35	35	35			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
S4802	165	0		29	10	S4802_165_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																								
S4802	204	0		29	10	S4802_204_0	2			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																								
S4802	204	0		29	10	S4802_204_0	2			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																								
S4802	204	0		29	10	S4802_204_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											85.99	15	15	15				85.99	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.62	50	50	50				49.62	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
S4802	204	0		29	10	S4802_204_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																								
S4802	205	0		29	10	S4802_205_0	2			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																								
S4802	205	0		29	10	S4802_205_0	2			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																								
S4802	205	0		29	10	S4802_205_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											90.09	15	15	15				90.09	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.16	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										35.00	70.00	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	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																								
S4802	206	0		29	10	S4802_206_0	2			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																								
S4802	206	0		29	10	S4802_206_0	2			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																								
S4802	206	0		29	10	S4802_206_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.89	15	15	15				87.89	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											64.55	50	50	50				64.55	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
S4802	206	0		29	10	S4802_206_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																								
S4802	207	0		29	10	S4802_207_0	2			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																								
S4802	207	0		29	10	S4802_207_0	2			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																								
S4802	207	0		29	10	S4802_207_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.94	15	15	15				86.94	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.83	50	50	50				55.83	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
S4802	207	0		29	10	S4802_207_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																								
S4802	208	0		29	10	S4802_208_0	2			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																								
S4802	208	0		29	10	S4802_208_0	2			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																								
S4802	208	0		29	10	S4802_208_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.38	15	15	15				87.38	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.58	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										35.00	70.00	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	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																								
S4802	209	0		29	10	S4802_209_0	2			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																								
S4802	209	0		29	10	S4802_209_0	2			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																								
S4802	209	0		29	10	S4802_209_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											89.17	15	15	15				89.17	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.36	50	50	50				52.36	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
S4802	209	0		29	10	S4802_209_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																								
S4802	210	0		29	10	S4802_210_0	2			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																								
S4802	210	0		29	10	S4802_210_0	2			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																								
S4802	210	0		29	10	S4802_210_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.97	15	15	15				86.97	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											51.24	50	50	50				51.24	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
S4802	210	0		29	10	S4802_210_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																								
S4802	211	0		29	10	S4802_211_0	2			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																								
S4802	211	0		29	10	S4802_211_0	2			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																								
S4802	211	0		29	10	S4802_211_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											90.12	15	15	15				90.12	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.57	50	50	50				47.57	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
S4802	211	0		29	10	S4802_211_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																								
S4802	212	0		29	10	S4802_212_0	2			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																								
S4802	212	0		29	10	S4802_212_0	2			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																								
S4802	212	0		29	10	S4802_212_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											89.99	15	15	15				89.99	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.81	50	50	50				46.81	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
S4802	212	0		29	10	S4802_212_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																								
S4802	213	0		29	10	S4802_213_0	2			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																								
S4802	213	0		29	10	S4802_213_0	2			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																								
S4802	213	0		29	10	S4802_213_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.10	15	15	15				88.10	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.53	50	50	50				47.53	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
S4802	213	0		29	10	S4802_213_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																								
S4802	214	0		29	10	S4802_214_0	2			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																								
S4802	214	0		29	10	S4802_214_0	2			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																								
S4802	214	0		29	10	S4802_214_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.32	15	15	15				88.32	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.06	50	50	50				53.06	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
S4802	214	0		29	10	S4802_214_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																								
S4802	215	0		29	10	S4802_215_0	2			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																								
S4802	215	0		29	10	S4802_215_0	2			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																								
S4802	215	0		29	10	S4802_215_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.59	15	15	15				88.59	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.35	50	50	50				45.35	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
S4802	215	0		29	10	S4802_215_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																								
S4802	216	0		29	10	S4802_216_0	2			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																								
S4802	216	0		29	10	S4802_216_0	2			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																								
S4802	216	0		29	10	S4802_216_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.13	15	15	15				86.13	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			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				47.70	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
S4802	216	0		29	10	S4802_216_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																								
S4802	217	0		29	10	S4802_217_0	2			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																								
S4802	217	0		29	10	S4802_217_0	2			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																								
S4802	217	0		29	10	S4802_217_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.87	15	15	15				87.87	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.95	50	50	50				46.95	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
S4802	217	0		29	10	S4802_217_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																								
S4802	218	0		29	10	S4802_218_0	2			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																								
S4802	218	0		29	10	S4802_218_0	2			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																								
S4802	218	0		29	10	S4802_218_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.76	15	15	15				87.76	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.93	50	50	50				45.93	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
S4802	218	0		29	10	S4802_218_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																								
S4802	219	0		29	10	S4802_219_0	2			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																								
S4802	219	0		29	10	S4802_219_0	2			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																								
S4802	219	0		29	10	S4802_219_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											89.34	15	15	15				89.34	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.47	50	50	50				53.47	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
S4802	219	0		29	10	S4802_219_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																								
S4802	220	0		29	10	S4802_220_0	2			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																								
S4802	220	0		29	10	S4802_220_0	2			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																								
S4802	220	0		29	10	S4802_220_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.34	15	15	15				88.34	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.74	50	50	50				50.74	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
S4802	220	0		29	10	S4802_220_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																								
S4802	221	0		29	10	S4802_221_0	2			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																								
S4802	221	0		29	10	S4802_221_0	2			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																								
S4802	221	0		29	10	S4802_221_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.86	15	15	15				88.86	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			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										35.00	70.00	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	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																								
S4802	222	0		29	10	S4802_222_0	2			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																								
S4802	222	0		29	10	S4802_222_0	2			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																								
S4802	222	0		29	10	S4802_222_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											89.40	15	15	15				89.40	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.28	50	50	50				43.28	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
S4802	222	0		29	10	S4802_222_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																								
S4802	223	0		29	10	S4802_223_0	2			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																								
S4802	223	0		29	10	S4802_223_0	2			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																								
S4802	223	0		29	10	S4802_223_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.92	15	15	15				88.92	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.77	50	50	50				41.77	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
S4802	223	0		29	10	S4802_223_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																								
S4802	224	0		29	10	S4802_224_0	2			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																								
S4802	224	0		29	10	S4802_224_0	2			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																								
S4802	224	0		29	10	S4802_224_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											91.92	15	15	15				91.92	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.65	50	50	50				47.65	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
S4802	224	0		29	10	S4802_224_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																								
S4802	225	0		29	10	S4802_225_0	2			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																								
S4802	225	0		29	10	S4802_225_0	2			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																								
S4802	225	0		29	10	S4802_225_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.95	15	15	15				87.95	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.96	50	50	50				50.96	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
S4802	225	0		29	10	S4802_225_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																								
S4802	226	0		29	10	S4802_226_0	2			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																								
S4802	226	0		29	10	S4802_226_0	2			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																								
S4802	226	0		29	10	S4802_226_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.30	15	15	15				88.30	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.55	50	50	50				43.55	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
S4802	226	0		29	10	S4802_226_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																								
S4802	227	0		29	10	S4802_227_0	2			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																								
S4802	227	0		29	10	S4802_227_0	2			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																								
S4802	227	0		29	10	S4802_227_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											89.51	15	15	15				89.51	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											51.19	50	50	50				51.19	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
S4802	227	0		29	10	S4802_227_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																								
S4802	228	0		29	10	S4802_228_0	2			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																								
S4802	228	0		29	10	S4802_228_0	2			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																								
S4802	228	0		29	10	S4802_228_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.19	15	15	15				86.19	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.86	50	50	50				47.86	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
S4802	228	0		29	10	S4802_228_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																								
S4802	229	0		29	10	S4802_229_0	2			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																								
S4802	229	0		29	10	S4802_229_0	2			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																								
S4802	229	0		29	10	S4802_229_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											89.40	15	15	15				89.40	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			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	50	50	50				48.91	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
S4802	229	0		29	10	S4802_229_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																								
S4802	230	0		29	10	S4802_230_0	2			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																								
S4802	230	0		29	10	S4802_230_0	2			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																								
S4802	230	0		29	10	S4802_230_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.69	15	15	15				87.69	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.96	50	50	50				59.96	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
S4802	230	0		29	10	S4802_230_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																								
S4802	231	0		29	10	S4802_231_0	2			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																								
S4802	231	0		29	10	S4802_231_0	2			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																								
S4802	231	0		29	10	S4802_231_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.31	15	15	15				88.31	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.19	50	50	50				53.19	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
S4802	231	0		29	10	S4802_231_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																								
S4802	232	0		29	10	S4802_232_0	2			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																								
S4802	232	0		29	10	S4802_232_0	2			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																								
S4802	232	0		29	10	S4802_232_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.87	15	15	15				87.87	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			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				49.79	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
S4802	232	0		29	10	S4802_232_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																								
S4802	233	0		29	10	S4802_233_0	2			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																								
S4802	233	0		29	10	S4802_233_0	2			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																								
S4802	233	0		29	10	S4802_233_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.79	15	15	15				87.79	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.31	50	50	50				49.31	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
S4802	233	0		29	10	S4802_233_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																								
S4802	234	0		29	10	S4802_234_0	2			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																								
S4802	234	0		29	10	S4802_234_0	2			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																								
S4802	234	0		29	10	S4802_234_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.43	15	15	15				88.43	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.55	50	50	50				45.55	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
S4802	234	0		29	10	S4802_234_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																								
S4802	235	0		29	10	S4802_235_0	2			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																								
S4802	235	0		29	10	S4802_235_0	2			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																								
S4802	235	0		29	10	S4802_235_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.61	15	15	15				88.61	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			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				58.60	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
S4802	235	0		29	10	S4802_235_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																								
S4802	236	0		29	10	S4802_236_0	2			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																								
S4802	236	0		29	10	S4802_236_0	2			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																								
S4802	236	0		29	10	S4802_236_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.74	15	15	15				88.74	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.71	50	50	50				49.71	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
S4802	236	0		29	10	S4802_236_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																								
S4802	237	0		29	10	S4802_237_0	2			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																								
S4802	237	0		29	10	S4802_237_0	2			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																								
S4802	237	0		29	10	S4802_237_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.31	15	15	15				86.31	15	15	15										15	15	15				15	15	15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	2			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				59.85	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
S4802	237	0		29	10	S4802_237_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																								
S5540	002	0		29	10	S5540_002_0	13			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	13			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					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
S5540	002	0		29	10	S5540_002_0	13			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.18	19	19	19				30.86	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
S5540	002	0		29	10	S5540_002_0	13			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											56.37	50	50	50				56.33	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
S5540	002	0		29	10	S5540_002_0	13			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	12			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	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					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	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					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	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.60	50	50	50				81.91	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
S5540	004	0		29	10	S5540_004_0	12			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				50.00	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
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				81.00	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		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	2			Preferred Generic	4	11	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		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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
S5552	005	0		29	10	S5552_005_0	2			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										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	2			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										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	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											69.00	50		50				54.00	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
S5552	005	0		29	10	S5552_005_0	2			Specialty Tier	4	11	1	1	5	1		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
S5552	006	0		29	10	S5552_006_0	2			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
S5552	006	0		29	10	S5552_006_0	2			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
S5552	006	0		29	10	S5552_006_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											38.00	17		17				40.00	17		17										17		17				17		17			17			17								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	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											53.00	35		35				38.00	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		105.00	35.00		105.00	35.00		35.00
S5552	006	0		29	10	S5552_006_0	2			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										35.00			35.00			35.00			35.00			35.00		35.00
S5584	001	0		29	10	S5584_001_0	4			Preferred Generic	3	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								6.00		18.00					1.00		3.00											6.00		18.00				1.00		3.00				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	001	0		29	10	S5584_001_0	4			Generic	3	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								11.00		33.00					6.00		18.00											11.00		33.00				6.00		18.00				11.00				11.00			0.35	0.19		0.35	0.19	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5584	001	0		29	10	S5584_001_0	4			Preferred Brand	3	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											90.00	23		23				90.00	23		23										23		23				23		23			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
S5584	001	0		29	10	S5584_001_0	4			Non-Preferred Drug	3	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	25		25				41.00	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		105.00	35.00		35.00
S5584	001	0		29	10	S5584_001_0	4			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	5			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	5			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	5			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	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											52.00	45		45				51.00	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	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
S5593	002	0		29	10	S5593_002_0	3			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	3			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	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											74.97	24		24				80.50	24		24												24						24			24			24								Preferred Generic, 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	3			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.80	50		50				50.05	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	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				31								31			31		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5593	003	0		29	10	S5593_003_0	3			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	3			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	3			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											81.55	25		25				90.16	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5593	003	0		29	10	S5593_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											58.41	49		49				48.47	49		49												49						49			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
S5593	003	0		29	10	S5593_003_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	001	0		29	10	S5596_001_0	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	001	0		29	10	S5596_001_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	001	0		29	10	S5596_001_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											82.83	15	15	15				82.83	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											93.32	40	40	40				93.32	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	001	0		29	10	S5596_001_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												26							26						26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	005	0		29	10	S5596_005_0	3			Preferred Generic	2	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	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	005	0		29	10	S5596_005_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											90.91	17	17	17				90.91	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		35.00
S5596	005	0		29	10	S5596_005_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											99.87	50	50	50				99.87	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	005	0		29	10	S5596_005_0	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	006	0		29	10	S5596_006_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	006	0		29	10	S5596_006_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											81.46	15	15	15				81.46	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											93.79	41	41	41				93.79	41	41	41				41	41	41															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
S5596	006	0		29	10	S5596_006_0	3			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																								
S5596	013	0		29	10	S5596_013_0	3			Preferred Generic	2	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	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	013	0		29	10	S5596_013_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											88.16	17	17	17				88.16	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		35.00
S5596	013	0		29	10	S5596_013_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											97.85	49	49	49				97.85	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		35.00
S5596	013	0		29	10	S5596_013_0	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	014	0		29	10	S5596_014_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	014	0		29	10	S5596_014_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											76.54	15	15	15				76.54	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											87.02	40	40	40				87.02	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	014	0		29	10	S5596_014_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												26							26						26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	017	0		29	10	S5596_017_0	3			Preferred Generic	2	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	017	0		29	10	S5596_017_0	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	017	0		29	10	S5596_017_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											80.93	17	17	17				80.93	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		35.00
S5596	017	0		29	10	S5596_017_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											79.05	44	44	44				79.05	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	70.00	105.00				35.00		35.00
S5596	017	0		29	10	S5596_017_0	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	018	0		29	10	S5596_018_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	018	0		29	10	S5596_018_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											74.09	15	15	15				74.09	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.83	40	40	40				84.83	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	018	0		29	10	S5596_018_0	3			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																								
S5596	043	0		29	10	S5596_043_0	3			Preferred Generic	2	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	043	0		29	10	S5596_043_0	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	043	0		29	10	S5596_043_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											79.96	17	17	17				79.96	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		35.00
S5596	043	0		29	10	S5596_043_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											89.76	48	48	48				89.76	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		35.00
S5596	043	0		29	10	S5596_043_0	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	044	0		29	10	S5596_044_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	044	0		29	10	S5596_044_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											78.98	15	15	15				78.98	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											88.28	43	43	43				86.23	42	42	42				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		35.00
S5596	044	0		29	10	S5596_044_0	3			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																								
S5596	046	0		29	10	S5596_046_0	3			Preferred Generic	2	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	046	0		29	10	S5596_046_0	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	046	0		29	10	S5596_046_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											96.44	17	17	17				96.44	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		35.00
S5596	046	0		29	10	S5596_046_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											104.02	50	50	50				104.02	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	046	0		29	10	S5596_046_0	3			Specialty Tier	2	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	3			Preferred Generic	2	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	056	0		29	10	S5596_056_0	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	056	0		29	10	S5596_056_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											81.41	17	17	17				81.41	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		35.00
S5596	056	0		29	10	S5596_056_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											79.75	40	40	40				79.75	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	70.00	105.00				35.00		35.00
S5596	056	0		29	10	S5596_056_0	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	057	0		29	10	S5596_057_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	057	0		29	10	S5596_057_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											85.78	15	15	15				85.78	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											99.56	49	49	49				99.56	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		35.00
S5596	057	0		29	10	S5596_057_0	3			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																								
S5596	059	0		29	10	S5596_059_0	4			Preferred Generic	2	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	059	0		29	10	S5596_059_0	4			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	059	0		29	10	S5596_059_0	4			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											99.46	18	18	18				99.46	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		35.00
S5596	059	0		29	10	S5596_059_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											101.01	39	39	39				98.42	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	059	0		29	10	S5596_059_0	4			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	060	0		29	10	S5596_060_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	060	0		29	10	S5596_060_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											70.10	15	15	15				70.10	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											93.05	38	38	38				93.05	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	060	0		29	10	S5596_060_0	3			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																								
S5596	062	0		29	10	S5596_062_0	3			Preferred Generic	2	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	062	0		29	10	S5596_062_0	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	062	0		29	10	S5596_062_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											89.78	17	17	17				89.78	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		35.00
S5596	062	0		29	10	S5596_062_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											106.41	40	40	40				106.41	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	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	063	0		29	10	S5596_063_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	063	0		29	10	S5596_063_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											66.35	15	15	15				66.35	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											92.43	38	38	38				92.43	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	063	0		29	10	S5596_063_0	3			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																								
S5596	085	0		29	10	S5596_085_0	3			Preferred Generic	2	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	085	0		29	10	S5596_085_0	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	085	0		29	10	S5596_085_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											82.72	17	17	17				82.72	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		35.00
S5596	085	0		29	10	S5596_085_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											93.10	43	43	43				93.10	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		35.00
S5596	085	0		29	10	S5596_085_0	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	086	0		29	10	S5596_086_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	086	0		29	10	S5596_086_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.20	15	15	15				65.20	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											89.58	40	40	40				89.58	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	086	0		29	10	S5596_086_0	3			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																								
S5596	087	0		29	10	S5596_087_0	3			Preferred Generic	2	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	087	0		29	10	S5596_087_0	3			Generic	2	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	14.00	21.00					4.00	8.00	12.00					4.00	8.00	12.00																7.00				7.00			0.23	0.13	0.13			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	087	0		29	10	S5596_087_0	3			Preferred Brand	2	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											87.89	17	17	17				87.89	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		35.00
S5596	087	0		29	10	S5596_087_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											104.21	39	39	39				104.21	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	087	0		29	10	S5596_087_0	3			Specialty Tier	2	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	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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																								
S5596	088	0		29	10	S5596_088_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								8.00	16.00	24.00					4.00	8.00	12.00					4.00	8.00	12.00																8.00				8.00			0.27	0.13	0.13			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5596	088	0		29	10	S5596_088_0	3			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.09	15	15	15				65.09	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											91.70	37	37	37				91.70	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		35.00
S5596	088	0		29	10	S5596_088_0	3			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																								
S5601	002	0		29	10	S5601_002_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				36.64	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
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				57.47	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		35.00
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				370.28	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	004	0		29	10	S5601_004_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				35.07	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
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				55.69	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		35.00
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				361.22	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	006	0		29	10	S5601_006_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				34.33	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
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				56.10	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		35.00
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				355.44	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	008	0		29	10	S5601_008_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				36.68	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
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				56.88	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		35.00
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				346.75	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	010	0		29	10	S5601_010_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				34.71	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
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				55.24	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		35.00
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				348.49	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	012	0		29	10	S5601_012_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				35.44	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		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				53.64	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		35.00
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				340.73	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	014	0		29	10	S5601_014_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				88.99	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
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				56.05	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
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				758.65	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	016	0		29	10	S5601_016_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				35.80	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
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				54.60	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		35.00
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				341.55	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	018	0		29	10	S5601_018_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				34.51	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
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				50.85	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		35.00
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				342.91	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	020	0		29	10	S5601_020_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				33.30	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
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				47.16	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		35.00
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				336.78	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	022	0		29	10	S5601_022_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				33.64	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
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				52.31	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		35.00
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				349.71	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	024	0		29	10	S5601_024_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				33.36	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
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				44.41	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		35.00
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				332.53	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	026	0		29	10	S5601_026_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				87.30	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
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				56.45	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		35.00
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				696.47	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	028	0		29	10	S5601_028_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				36.81	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
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				54.67	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		35.00
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				332.06	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	030	0		29	10	S5601_030_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				30.33	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
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				48.26	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		35.00
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				331.85	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	032	0		29	10	S5601_032_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				71.17	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
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				54.45	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
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				649.89	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	034	0		29	10	S5601_034_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				35.80	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
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				50.44	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		35.00
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				334.93	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	036	0		29	10	S5601_036_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				29.56	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
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				49.24	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		35.00
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				330.08	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	038	0		29	10	S5601_038_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				71.80	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
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				49.55	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
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				727.37	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	040	0		29	10	S5601_040_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				31.12	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
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				46.35	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		35.00
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				325.38	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	042	0		29	10	S5601_042_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				28.94	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
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				45.21	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		35.00
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				325.54	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	044	0		29	10	S5601_044_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				31.45	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
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				55.52	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		35.00
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				335.79	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	046	0		29	10	S5601_046_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				32.18	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
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				56.98	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		35.00
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				338.89	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	048	0		29	10	S5601_048_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				78.79	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
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				50.20	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
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				648.79	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	050	0		29	10	S5601_050_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				74.51	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
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				53.48	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
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				668.61	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	052	0		29	10	S5601_052_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				32.24	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
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				55.53	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		35.00
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				363.06	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	054	0		29	10	S5601_054_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				35.24	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		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				58.20	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		35.00
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				365.94	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	056	0		29	10	S5601_056_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				38.10	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
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				62.24	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		35.00
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				351.31	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	058	0		29	10	S5601_058_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				36.04	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
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				59.69	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		35.00
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				344.32	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	060	0		29	10	S5601_060_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				80.01	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
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				55.77	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
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				817.44	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	062	0		29	10	S5601_062_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				34.02	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
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				53.36	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		35.00
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				335.32	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	064	0		29	10	S5601_064_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				33.42	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
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				60.99	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		35.00
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				358.78	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	066	0		29	10	S5601_066_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				81.06	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
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				75.29	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
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				758.28	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5601	068	0		29	10	S5601_068_0	3			Preferred Generic	2	11	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	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																								
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	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																								
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				35.76	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
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				62.23	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		35.00
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				352.31	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5617	003	0		29	10	S5617_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								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	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					3.00	6.00	9.00											11.00	22.00	33.00				3.00	6.00	3.00				11.00				11.00			0.37	0.10		0.37	0.10	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	3.00	6.00	9.00	11.00	22.00	33.00	3.00	6.00	3.00	11.00		11.00
S5617	003	0		29	10	S5617_003_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.46	20	20	20				41.17	16	16	16										20	20	20				16	16	16			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	003	0		29	10	S5617_003_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.23	49	49	49				42.08	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	003	0		29	10	S5617_003_0	4			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	3			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	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					3.00	6.00	9.00											11.00	22.00	33.00				3.00	6.00	3.00				11.00				11.00			0.37	0.10		0.37	0.10	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	3.00	6.00	9.00	11.00	22.00	33.00	3.00	6.00	3.00	11.00		11.00
S5617	008	0		29	10	S5617_008_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.59	20	20	20				45.74	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	008	0		29	10	S5617_008_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.26	50	50	50				42.07	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	008	0		29	10	S5617_008_0	3			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	3			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	013	0		29	10	S5617_013_0	3			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					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	3.00				10.00				10.00			0.33	0.07		0.33	0.07	0.33	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										10.00	20.00	30.00	2.00	4.00	6.00	10.00	20.00	30.00	2.00	4.00	3.00	10.00		10.00
S5617	013	0		29	10	S5617_013_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.50	18	18	18				41.29	16	16	16										18	18	18				16	16	16			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	013	0		29	10	S5617_013_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.23	41	41	41				44.45	41	41	41										41	41	41				41	41	41			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
S5617	013	0		29	10	S5617_013_0	3			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	3			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	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	3.00				11.00				11.00			0.37	0.07		0.37	0.07	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	2.00	4.00	6.00	11.00	22.00	33.00	2.00	4.00	3.00	11.00		11.00
S5617	018	0		29	10	S5617_018_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.28	19	19	19				45.79	17	17	17										19	19	19				17	17	17			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	018	0		29	10	S5617_018_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.84	46	46	46				46.45	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	3			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	3			Preferred Generic	2	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
S5617	053	0		29	10	S5617_053_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	053	0		29	10	S5617_053_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.51	20	20	20				49.80	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	053	0		29	10	S5617_053_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.81	50	50	50				44.30	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	053	0		29	10	S5617_053_0	3			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	3			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					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	0.30	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
S5617	068	0		29	10	S5617_068_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	068	0		29	10	S5617_068_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.34	24	24	24				45.30	17	17	17										24	24	24				17	17	17			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
S5617	068	0		29	10	S5617_068_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.25	50	50	50				38.89	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	068	0		29	10	S5617_068_0	3			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	3			Preferred Generic	2	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	0.17	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
S5617	088	0		29	10	S5617_088_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	088	0		29	10	S5617_088_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.45	20	20	20				49.58	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	088	0		29	10	S5617_088_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.65	50	50	50				37.71	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	088	0		29	10	S5617_088_0	3			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	3			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	3			Generic	2	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					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	3.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	3.00	12.00		12.00
S5617	103	0		29	10	S5617_103_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.33	20	20	20				47.61	17	17	17										20	20	20				17	17	17			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	103	0		29	10	S5617_103_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.70	50	50	50				47.27	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	103	0		29	10	S5617_103_0	3			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	3			Preferred Generic	2	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
S5617	108	0		29	10	S5617_108_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	108	0		29	10	S5617_108_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.41	22	22	22				50.86	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.08	50	50	50				42.65	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	108	0		29	10	S5617_108_0	3			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	3			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					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	0.20	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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
S5617	113	0		29	10	S5617_113_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	113	0		29	10	S5617_113_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.54	21	21	21				51.09	18	18	18										21	21	21				18	18	18			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	113	0		29	10	S5617_113_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											48.86	50	50	50				40.55	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	113	0		29	10	S5617_113_0	3			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	3			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	3			Generic	2	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					3.00	6.00	9.00											12.00	24.00	36.00				3.00	6.00	3.00				12.00				12.00			0.40	0.10		0.40	0.10	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00	12.00	24.00	36.00	3.00	6.00	3.00	12.00		12.00
S5617	118	0		29	10	S5617_118_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.36	19	19	19				41.60	16	16	16										19	19	19				16	16	16			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	118	0		29	10	S5617_118_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.80	50	50	50				40.29	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	118	0		29	10	S5617_118_0	3			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	3			Preferred Generic	2	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	0.17	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
S5617	123	0		29	10	S5617_123_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	123	0		29	10	S5617_123_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.97	20	20	20				46.51	17	17	17										20	20	20				17	17	17			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	123	0		29	10	S5617_123_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.65	50	50	50				36.98	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	123	0		29	10	S5617_123_0	3			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	4			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	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					3.00	6.00	9.00											16.00	32.00	48.00				3.00	6.00	3.00				16.00				16.00			0.53	0.10		0.53	0.10	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	3.00	6.00	9.00	16.00	32.00	48.00	3.00	6.00	3.00	16.00		16.00
S5617	128	0		29	10	S5617_128_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.19	19	19	19				49.45	17	17	17										19	19	19				17	17	17			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	128	0		29	10	S5617_128_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											72.96	50	50	50				62.15	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	128	0		29	10	S5617_128_0	4			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	3			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	3			Generic	2	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					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	3.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	3.00	12.00		12.00
S5617	133	0		29	10	S5617_133_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.29	19	19	19				44.71	17	17	17										19	19	19				17	17	17			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	133	0		29	10	S5617_133_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.58	50	50	50				50.75	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	133	0		29	10	S5617_133_0	3			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	3			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	3			Generic	2	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					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	3.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	3.00	12.00		12.00
S5617	138	0		29	10	S5617_138_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											50.48	20	20	20				45.10	17	17	17										20	20	20				17	17	17			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	138	0		29	10	S5617_138_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.04	50	50	50				53.16	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	138	0		29	10	S5617_138_0	3			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	3			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					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	0.20	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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
S5617	143	0		29	10	S5617_143_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	143	0		29	10	S5617_143_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.73	20	20	20				49.15	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	143	0		29	10	S5617_143_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											60.20	50	50	50				56.64	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	143	0		29	10	S5617_143_0	3			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	3			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	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								13.00	26.00	39.00					2.00	4.00	6.00											13.00	26.00	39.00				2.00	4.00	3.00				13.00				13.00			0.43	0.07		0.43	0.07	0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	39.00	2.00	4.00	6.00	13.00	26.00	39.00	2.00	4.00	3.00	13.00		13.00
S5617	148	0		29	10	S5617_148_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.67	19	19	19				40.81	17	17	17										19	19	19				17	17	17			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	148	0		29	10	S5617_148_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.88	50	50	50				46.41	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	148	0		29	10	S5617_148_0	3			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	3			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	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					3.00	6.00	9.00											16.00	32.00	48.00				3.00	6.00	3.00				16.00				16.00			0.53	0.10		0.53	0.10	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	3.00	6.00	9.00	16.00	32.00	48.00	3.00	6.00	3.00	16.00		16.00
S5617	153	0		29	10	S5617_153_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.27	19	19	19				43.62	17	17	17										19	19	19				17	17	17			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	153	0		29	10	S5617_153_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.76	50	50	50				44.58	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	153	0		29	10	S5617_153_0	3			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	3			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	158	0		29	10	S5617_158_0	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	3.00				11.00				11.00			0.37	0.07		0.37	0.07	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	2.00	4.00	6.00	11.00	22.00	33.00	2.00	4.00	3.00	11.00		11.00
S5617	158	0		29	10	S5617_158_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.57	19	19	19				42.40	16	16	16										19	19	19				16	16	16			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	158	0		29	10	S5617_158_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.38	50	50	50				48.42	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	158	0		29	10	S5617_158_0	3			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	4			Preferred Generic	2	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	0.17	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
S5617	163	0		29	10	S5617_163_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					2.00	4.00	6.00											16.00	32.00	48.00				2.00	4.00	3.00				16.00				16.00			0.53	0.07		0.53	0.07	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	2.00	4.00	6.00	16.00	32.00	48.00	2.00	4.00	3.00	16.00		16.00
S5617	163	0		29	10	S5617_163_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.92	20	20	20				49.81	17	17	17										20	20	20				17	17	17			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	163	0		29	10	S5617_163_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.60	50	50	50				45.92	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
S5617	163	0		29	10	S5617_163_0	4			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	3			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	3			Generic	2	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					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	3.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	3.00	12.00		12.00
S5617	214	0		29	10	S5617_214_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.04	20	20	20				45.52	17	17	17										20	20	20				17	17	17			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	214	0		29	10	S5617_214_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.24	50	50	50				47.17	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	214	0		29	10	S5617_214_0	3			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	3			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	3			Generic	2	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					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	3.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	3.00	12.00		12.00
S5617	215	0		29	10	S5617_215_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.64	20	20	20				43.98	16	16	16										20	20	20				16	16	16			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	215	0		29	10	S5617_215_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.62	48	48	48				41.47	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	215	0		29	10	S5617_215_0	3			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	3			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					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	0.20	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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
S5617	216	0		29	10	S5617_216_0	3			Generic	2	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					3.00	6.00	9.00											19.00	38.00	57.00				3.00	6.00	3.00				19.00				19.00			0.63	0.10		0.63	0.10	0.63	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00	3.00	6.00	9.00	19.00	38.00	57.00	3.00	6.00	3.00	19.00		19.00
S5617	216	0		29	10	S5617_216_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.78	22	22	22				51.26	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.88	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										35.00	70.00	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	3			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	3			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					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	0.20	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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
S5617	217	0		29	10	S5617_217_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	217	0		29	10	S5617_217_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.38	22	22	22				50.85	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.03	50	50	50				42.33	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	217	0		29	10	S5617_217_0	3			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	3			Preferred Generic	2	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	0.27	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
S5617	218	0		29	10	S5617_218_0	3			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	218	0		29	10	S5617_218_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.13	22	22	22				51.14	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.94	50	50	50				41.24	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	218	0		29	10	S5617_218_0	3			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	3			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					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	0.20	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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
S5617	219	0		29	10	S5617_219_0	3			Generic	2	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					3.00	6.00	9.00											19.00	38.00	57.00				3.00	6.00	3.00				19.00				19.00			0.63	0.10		0.63	0.10	0.63	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00	3.00	6.00	9.00	19.00	38.00	57.00	3.00	6.00	3.00	19.00		19.00
S5617	219	0		29	10	S5617_219_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.44	21	21	21				47.75	18	18	18										21	21	21				18	18	18			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	219	0		29	10	S5617_219_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.49	50	50	50				41.45	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	219	0		29	10	S5617_219_0	3			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	3			Preferred Generic	2	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	0.17	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
S5617	220	0		29	10	S5617_220_0	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								18.00	36.00	54.00					3.00	6.00	9.00											18.00	36.00	54.00				3.00	6.00	3.00				18.00				18.00			0.60	0.10		0.60	0.10	0.60	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										18.00	36.00	54.00	3.00	6.00	9.00	18.00	36.00	54.00	3.00	6.00	3.00	18.00		18.00
S5617	220	0		29	10	S5617_220_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.96	21	21	21				47.91	18	18	18										21	21	21				18	18	18			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	220	0		29	10	S5617_220_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.19	50	50	50				39.35	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	220	0		29	10	S5617_220_0	3			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	3			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	221	0		29	10	S5617_221_0	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	3.00				11.00				11.00			0.37	0.07		0.37	0.07	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	2.00	4.00	6.00	11.00	22.00	33.00	2.00	4.00	3.00	11.00		11.00
S5617	221	0		29	10	S5617_221_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.65	20	20	20				39.80	16	16	16										20	20	20				16	16	16			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	221	0		29	10	S5617_221_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.33	50	50	50				43.83	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	221	0		29	10	S5617_221_0	3			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	3			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	3			Generic	2	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					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	3.00				15.00				15.00			0.50	0.10		0.50	0.10	0.50	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	3.00	15.00		15.00
S5617	222	0		29	10	S5617_222_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.64	20	20	20				44.56	17	17	17										20	20	20				17	17	17			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	222	0		29	10	S5617_222_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.21	50	50	50				40.17	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	222	0		29	10	S5617_222_0	3			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	3			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	223	0		29	10	S5617_223_0	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	3.00				11.00				11.00			0.37	0.07		0.37	0.07	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	2.00	4.00	6.00	11.00	22.00	33.00	2.00	4.00	3.00	11.00		11.00
S5617	223	0		29	10	S5617_223_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.81	18	18	18				38.93	16	16	16										18	18	18				16	16	16			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	223	0		29	10	S5617_223_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.43	47	47	47				44.87	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	223	0		29	10	S5617_223_0	3			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	3			Preferred Generic	2	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
S5617	224	0		29	10	S5617_224_0	3			Generic	2	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					3.00	6.00	9.00											19.00	38.00	57.00				3.00	6.00	3.00				19.00				19.00			0.63	0.10		0.63	0.10	0.63	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00	3.00	6.00	9.00	19.00	38.00	57.00	3.00	6.00	3.00	19.00		19.00
S5617	224	0		29	10	S5617_224_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.71	21	21	21				49.06	18	18	18										21	21	21				18	18	18			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	224	0		29	10	S5617_224_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.53	50	50	50				42.97	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	224	0		29	10	S5617_224_0	3			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	3			Preferred Generic	2	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	0.17	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
S5617	225	0		29	10	S5617_225_0	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					2.00	4.00	6.00											16.00	32.00	48.00				2.00	4.00	3.00				16.00				16.00			0.53	0.07		0.53	0.07	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	2.00	4.00	6.00	16.00	32.00	48.00	2.00	4.00	3.00	16.00		16.00
S5617	225	0		29	10	S5617_225_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.73	20	20	20				43.07	17	17	17										20	20	20				17	17	17			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	225	0		29	10	S5617_225_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.81	50	50	50				41.72	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	225	0		29	10	S5617_225_0	3			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	3			Preferred Generic	2	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	0.17	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
S5617	226	0		29	10	S5617_226_0	3			Generic	2	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					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	3.00				15.00				15.00			0.50	0.10		0.50	0.10	0.50	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	3.00	15.00		15.00
S5617	226	0		29	10	S5617_226_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.43	20	20	20				45.17	17	17	17										20	20	20				17	17	17			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	226	0		29	10	S5617_226_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.10	50	50	50				34.78	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	226	0		29	10	S5617_226_0	3			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	3			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	3			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					3.00	6.00	9.00											16.00	32.00	48.00				3.00	6.00	3.00				16.00				16.00			0.53	0.10		0.53	0.10	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	3.00	6.00	9.00	16.00	32.00	48.00	3.00	6.00	3.00	16.00		16.00
S5617	227	0		29	10	S5617_227_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.81	20	20	20				43.93	16	16	16										20	20	20				16	16	16			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	227	0		29	10	S5617_227_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.39	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										35.00	70.00	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	3			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	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					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	0.33	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	0.00	10.00		10.00
S5617	246	0		29	10	S5617_246_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								19.00	38.00	57.00					8.00	16.00	24.00											19.00	38.00	57.00				8.00	16.00	5.00				19.00				19.00			0.63	0.27		0.63	0.27	0.63	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00	8.00	16.00	24.00	19.00	38.00	57.00	8.00	16.00	5.00	19.00		19.00
S5617	246	0		29	10	S5617_246_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.78	22	22	22				47.26	19	19	19										22	22	22				19	19	19			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.96	50	50	50				36.29	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	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	247	0		29	10	S5617_247_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.27		0.67	0.27	0.67	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	5.00	20.00		20.00
S5617	247	0		29	10	S5617_247_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.16	23	23	23				50.06	19	19	19										23	23	23				19	19	19			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.40	50	50	50				38.17	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	4			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	4			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	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	0.20	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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
S5617	248	0		29	10	S5617_248_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					8.00	16.00	24.00											17.00	34.00	51.00				8.00	16.00	5.00				17.00				17.00			0.57	0.27		0.57	0.27	0.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										17.00	34.00	51.00	8.00	16.00	24.00	17.00	34.00	51.00	8.00	16.00	5.00	17.00		17.00
S5617	248	0		29	10	S5617_248_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.91	19	19	19				42.30	17	17	17										19	19	19				17	17	17			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	248	0		29	10	S5617_248_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.35	42	42	42				39.80	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	248	0		29	10	S5617_248_0	4			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	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					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	0.33	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	0.00	10.00		10.00
S5617	249	0		29	10	S5617_249_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.27		0.67	0.27	0.67	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	5.00	20.00		20.00
S5617	249	0		29	10	S5617_249_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											50.52	21	21	21				43.62	18	18	18										21	21	21				18	18	18			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	249	0		29	10	S5617_249_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.24	48	48	48				39.08	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	249	0		29	10	S5617_249_0	4			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	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					1.00	2.00	3.00											9.00	18.00	27.00				1.00	2.00	0.00				9.00				9.00			0.30	0.03		0.30	0.03	0.30	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	0.00	9.00		9.00
S5617	250	0		29	10	S5617_250_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.30		0.67	0.30	0.67	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	5.00	20.00		20.00
S5617	250	0		29	10	S5617_250_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.53	23	23	23				48.45	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.46	50	50	50				38.64	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	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	251	0		29	10	S5617_251_0	4			Generic	4	01	3	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	0.67	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	251	0		29	10	S5617_251_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.10	23	23	23				51.20	19	19	19										23	23	23				19	19	19			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.69	50	50	50				35.86	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	251	0		29	10	S5617_251_0	4			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	4			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					1.00	2.00	3.00											11.00	22.00	33.00				1.00	2.00	0.00				11.00				11.00			0.37	0.03		0.37	0.03	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	1.00	2.00	3.00	11.00	22.00	33.00	1.00	2.00	0.00	11.00		11.00
S5617	252	0		29	10	S5617_252_0	4			Generic	4	01	3	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	0.67	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	252	0		29	10	S5617_252_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											50.24	22	22	22				43.91	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.71	50	50	50				39.91	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	4			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	4			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					1.00	2.00	3.00											11.00	22.00	33.00				1.00	2.00	0.00				11.00				11.00			0.37	0.03		0.37	0.03	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	1.00	2.00	3.00	11.00	22.00	33.00	1.00	2.00	0.00	11.00		11.00
S5617	253	0		29	10	S5617_253_0	4			Generic	4	01	3	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	0.67	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	253	0		29	10	S5617_253_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.17	23	23	23				45.64	19	19	19										23	23	23				19	19	19			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.08	50	50	50				37.90	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	4			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	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					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	0.33	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	0.00	10.00		10.00
S5617	254	0		29	10	S5617_254_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.27		0.67	0.27	0.67	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	5.00	20.00		20.00
S5617	254	0		29	10	S5617_254_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.24	24	24	24				46.05	19	19	19										24	24	24				19	19	19			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
S5617	254	0		29	10	S5617_254_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.19	50	50	50				32.54	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	4			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	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					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	0.33	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	0.00	10.00		10.00
S5617	255	0		29	10	S5617_255_0	4			Generic	4	01	3	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	0.67	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	255	0		29	10	S5617_255_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.97	22	22	22				43.38	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.88	50	50	50				37.15	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	255	0		29	10	S5617_255_0	4			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	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					1.00	2.00	3.00											9.00	18.00	27.00				1.00	2.00	0.00				9.00				9.00			0.30	0.03		0.30	0.03	0.30	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	0.00	9.00		9.00
S5617	256	0		29	10	S5617_256_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.27		0.67	0.27	0.67	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	5.00	20.00		20.00
S5617	256	0		29	10	S5617_256_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.22	22	22	22				41.64	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.35	50	50	50				36.76	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	256	0		29	10	S5617_256_0	4			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	4			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					1.00	2.00	3.00											11.00	22.00	33.00				1.00	2.00	0.00				11.00				11.00			0.37	0.03		0.37	0.03	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	1.00	2.00	3.00	11.00	22.00	33.00	1.00	2.00	0.00	11.00		11.00
S5617	257	0		29	10	S5617_257_0	4			Generic	4	01	3	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	0.67	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	257	0		29	10	S5617_257_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.92	24	24	24				42.16	18	18	18										24	24	24				18	18	18			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
S5617	257	0		29	10	S5617_257_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.15	50	50	50				36.01	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	257	0		29	10	S5617_257_0	4			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								12.00	24.00	36.00					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	0.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	0.00	12.00		12.00
S5617	258	0		29	10	S5617_258_0	5			Generic	4	01	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											20.00	40.00	60.00				10.00	20.00	6.00				20.00				20.00			0.67	0.33		0.67	0.33	0.67	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	6.00	20.00		20.00
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											56.72	23	23	23				51.26	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	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.04	50	50	50				35.50	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	4			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					3.00	6.00	9.00											12.00	24.00	36.00				3.00	6.00	0.00				12.00				12.00			0.40	0.10		0.40	0.10	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00	12.00	24.00	36.00	3.00	6.00	0.00	12.00		12.00
S5617	259	0		29	10	S5617_259_0	4			Generic	4	01	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											20.00	40.00	60.00				10.00	20.00	6.00				20.00				20.00			0.67	0.33		0.67	0.33	0.67	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	6.00	20.00		20.00
S5617	259	0		29	10	S5617_259_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.97	23	23	23				52.66	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.64	50	50	50				33.28	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	259	0		29	10	S5617_259_0	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	260	0		29	10	S5617_260_0	4			Generic	4	01	3	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	0.67	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	260	0		29	10	S5617_260_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.51	23	23	23				43.13	18	18	18										23	23	23				18	18	18			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.38	50	50	50				34.34	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	260	0		29	10	S5617_260_0	4			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	4			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					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	0.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	0.00	12.00		12.00
S5617	261	0		29	10	S5617_261_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								19.00	38.00	57.00					10.00	20.00	30.00											19.00	38.00	57.00				10.00	20.00	5.00				19.00				19.00			0.63	0.33		0.63	0.33	0.63	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00	10.00	20.00	30.00	19.00	38.00	57.00	10.00	20.00	5.00	19.00		19.00
S5617	261	0		29	10	S5617_261_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											60.59	23	23	23				50.48	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	261	0		29	10	S5617_261_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.42	50	50	50				37.14	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
S5617	261	0		29	10	S5617_261_0	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	262	0		29	10	S5617_262_0	4			Generic	4	01	3	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	0.67	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	262	0		29	10	S5617_262_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.02	23	23	23				46.93	19	19	19										23	23	23				19	19	19			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.95	50	50	50				37.35	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	4			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	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					1.00	2.00	3.00											9.00	18.00	27.00				1.00	2.00	0.00				9.00				9.00			0.30	0.03		0.30	0.03	0.30	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	0.00	9.00		9.00
S5617	263	0		29	10	S5617_263_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.30		0.67	0.30	0.67	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	5.00	20.00		20.00
S5617	263	0		29	10	S5617_263_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.17	23	23	23				47.43	19	19	19										23	23	23				19	19	19			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.58	50	50	50				37.46	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	263	0		29	10	S5617_263_0	4			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	4			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					1.00	2.00	3.00											8.00	16.00	24.00				1.00	2.00	0.00				8.00				8.00			0.27	0.03		0.27	0.03	0.27	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										8.00	16.00	24.00	1.00	2.00	3.00	8.00	16.00	24.00	1.00	2.00	0.00	8.00		8.00
S5617	264	0		29	10	S5617_264_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								18.00	36.00	54.00					8.00	16.00	24.00											18.00	36.00	54.00				8.00	16.00	5.00				18.00				18.00			0.60	0.27		0.60	0.27	0.60	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										18.00	36.00	54.00	8.00	16.00	24.00	18.00	36.00	54.00	8.00	16.00	5.00	18.00		18.00
S5617	264	0		29	10	S5617_264_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.41	22	22	22				44.80	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.71	47	47	47				38.05	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	264	0		29	10	S5617_264_0	4			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	4			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					1.00	2.00	3.00											8.00	16.00	24.00				1.00	2.00	0.00				8.00				8.00			0.27	0.03		0.27	0.03	0.27	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										8.00	16.00	24.00	1.00	2.00	3.00	8.00	16.00	24.00	1.00	2.00	0.00	8.00		8.00
S5617	265	0		29	10	S5617_265_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								18.00	36.00	54.00					8.00	16.00	24.00											18.00	36.00	54.00				8.00	16.00	5.00				18.00				18.00			0.60	0.27		0.60	0.27	0.60	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										18.00	36.00	54.00	8.00	16.00	24.00	18.00	36.00	54.00	8.00	16.00	5.00	18.00		18.00
S5617	265	0		29	10	S5617_265_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											50.05	22	22	22				44.47	19	19	19										22	22	22				19	19	19			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.97	47	47	47				28.79	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	265	0		29	10	S5617_265_0	4			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	4			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					1.00	2.00	3.00											7.00	14.00	21.00				1.00	2.00	0.00				7.00				7.00			0.23	0.03		0.23	0.03	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00	14.00	21.00	1.00	2.00	3.00	7.00	14.00	21.00	1.00	2.00	0.00	7.00		7.00
S5617	266	0		29	10	S5617_266_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					8.00	16.00	24.00											17.00	34.00	51.00				8.00	16.00	5.00				17.00				17.00			0.57	0.27		0.57	0.27	0.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										17.00	34.00	51.00	8.00	16.00	24.00	17.00	34.00	51.00	8.00	16.00	5.00	17.00		17.00
S5617	266	0		29	10	S5617_266_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.36	21	21	21				39.79	18	18	18										21	21	21				18	18	18			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	266	0		29	10	S5617_266_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.66	45	45	45				34.49	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
S5617	266	0		29	10	S5617_266_0	4			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	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					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	0.33	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	0.00	10.00		10.00
S5617	267	0		29	10	S5617_267_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.27		0.67	0.27	0.67	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	5.00	20.00		20.00
S5617	267	0		29	10	S5617_267_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.45	22	22	22				51.32	20	20	20										22	22	22				20	20	20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.75	50	50	50				36.50	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	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	268	0		29	10	S5617_268_0	4			Generic	4	01	3	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	0.67	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	268	0		29	10	S5617_268_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.02	23	23	23				49.30	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											48.59	50	50	50				38.89	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	268	0		29	10	S5617_268_0	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	269	0		29	10	S5617_269_0	4			Generic	4	01	3	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	0.67	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	269	0		29	10	S5617_269_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.41	22	22	22				48.99	19	19	19										22	22	22				19	19	19			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.07	50	50	50				35.77	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	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	270	0		29	10	S5617_270_0	4			Generic	4	01	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											20.00	40.00	60.00				10.00	20.00	6.00				20.00				20.00			0.67	0.33		0.67	0.33	0.67	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	6.00	20.00		20.00
S5617	270	0		29	10	S5617_270_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.39	23	23	23				51.01	19	19	19										23	23	23				19	19	19			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.05	50	50	50				34.23	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	270	0		29	10	S5617_270_0	4			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	4			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					1.00	2.00	3.00											7.00	14.00	21.00				1.00	2.00	0.00				7.00				7.00			0.23	0.03		0.23	0.03	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00	14.00	21.00	1.00	2.00	3.00	7.00	14.00	21.00	1.00	2.00	0.00	7.00		7.00
S5617	271	0		29	10	S5617_271_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								19.00	38.00	57.00					8.00	16.00	24.00											19.00	38.00	57.00				8.00	16.00	5.00				19.00				19.00			0.63	0.27		0.63	0.27	0.63	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00	8.00	16.00	24.00	19.00	38.00	57.00	8.00	16.00	5.00	19.00		19.00
S5617	271	0		29	10	S5617_271_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.69	22	22	22				42.23	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.09	47	47	47				37.68	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	271	0		29	10	S5617_271_0	4			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	4			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					1.00	2.00	3.00											12.00	24.00	36.00				1.00	2.00	0.00				12.00				12.00			0.40	0.03		0.40	0.03	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	1.00	2.00	3.00	12.00	24.00	36.00	1.00	2.00	0.00	12.00		12.00
S5617	272	0		29	10	S5617_272_0	4			Generic	4	01	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											20.00	40.00	60.00				10.00	20.00	6.00				20.00				20.00			0.67	0.33		0.67	0.33	0.67	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	6.00	20.00		20.00
S5617	272	0		29	10	S5617_272_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.85	23	23	23				47.58	19	19	19										23	23	23				19	19	19			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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.53	50	50	50				40.40	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	272	0		29	10	S5617_272_0	4			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	4			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					2.00	4.00	6.00											12.00	24.00	36.00				2.00	4.00	0.00				12.00				12.00			0.40	0.07		0.40	0.07	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	0.00	12.00		12.00
S5617	273	0		29	10	S5617_273_0	4			Generic	4	01	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											20.00	40.00	60.00				10.00	20.00	5.00				20.00				20.00			0.67	0.33		0.67	0.33	0.67	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	5.00	20.00		20.00
S5617	273	0		29	10	S5617_273_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.06	23	23	23				46.99	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.71	50	50	50				36.59	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	273	0		29	10	S5617_273_0	4			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	4			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					1.00	2.00	3.00											11.00	22.00	33.00				1.00	2.00	0.00				11.00				11.00			0.37	0.03		0.37	0.03	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	1.00	2.00	3.00	11.00	22.00	33.00	1.00	2.00	0.00	11.00		11.00
S5617	274	0		29	10	S5617_274_0	4			Generic	4	01	3	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	0.67	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	274	0		29	10	S5617_274_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.51	23	23	23				49.80	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											48.58	50	50	50				41.68	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	4			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	4			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					3.00	6.00	9.00											12.00	24.00	36.00				3.00	6.00	0.00				12.00				12.00			0.40	0.10		0.40	0.10	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00	12.00	24.00	36.00	3.00	6.00	0.00	12.00		12.00
S5617	275	0		29	10	S5617_275_0	4			Generic	4	01	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											20.00	40.00	60.00				10.00	20.00	6.00				20.00				20.00			0.67	0.33		0.67	0.33	0.67	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	6.00	20.00		20.00
S5617	275	0		29	10	S5617_275_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.50	23	23	23				50.79	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	275	0		29	10	S5617_275_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.29	50	50	50				31.28	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	275	0		29	10	S5617_275_0	4			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	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					1.00	2.00	3.00											9.00	18.00	27.00				1.00	2.00	0.00				9.00				9.00			0.30	0.03		0.30	0.03	0.30	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	0.00	9.00		9.00
S5617	276	0		29	10	S5617_276_0	4			Generic	4	01	3	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	5.00				20.00				20.00			0.67	0.27		0.67	0.27	0.67	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	5.00	20.00		20.00
S5617	276	0		29	10	S5617_276_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.14	22	22	22				45.88	19	19	19										22	22	22				19	19	19			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.84	50	50	50				33.56	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	4			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	4			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					1.00	2.00	3.00											8.00	16.00	24.00				1.00	2.00	0.00				8.00				8.00			0.27	0.03		0.27	0.03	0.27	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										8.00	16.00	24.00	1.00	2.00	3.00	8.00	16.00	24.00	1.00	2.00	0.00	8.00		8.00
S5617	277	0		29	10	S5617_277_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								19.00	38.00	57.00					8.00	16.00	24.00											19.00	38.00	57.00				8.00	16.00	5.00				19.00				19.00			0.63	0.27		0.63	0.27	0.63	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										19.00	38.00	57.00	8.00	16.00	24.00	19.00	38.00	57.00	8.00	16.00	5.00	19.00		19.00
S5617	277	0		29	10	S5617_277_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.21	22	22	22				44.06	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.07	47	47	47				38.95	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	277	0		29	10	S5617_277_0	4			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	4			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					1.00	2.00	3.00											7.00	14.00	21.00				1.00	2.00	0.00				7.00				7.00			0.23	0.03		0.23	0.03	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00	14.00	21.00	1.00	2.00	3.00	7.00	14.00	21.00	1.00	2.00	0.00	7.00		7.00
S5617	278	0		29	10	S5617_278_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								18.00	36.00	54.00					8.00	16.00	24.00											18.00	36.00	54.00				8.00	16.00	5.00				18.00				18.00			0.60	0.27		0.60	0.27	0.60	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										18.00	36.00	54.00	8.00	16.00	24.00	18.00	36.00	54.00	8.00	16.00	5.00	18.00		18.00
S5617	278	0		29	10	S5617_278_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.61	21	21	21				48.11	17	17	17										21	21	21				17	17	17			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	278	0		29	10	S5617_278_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.05	47	47	47				48.61	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	4			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	4			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					3.00	6.00	9.00											12.00	24.00	36.00				3.00	6.00	0.00				12.00				12.00			0.40	0.10		0.40	0.10	0.40	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										12.00	24.00	36.00	3.00	6.00	9.00	12.00	24.00	36.00	3.00	6.00	0.00	12.00		12.00
S5617	279	0		29	10	S5617_279_0	4			Generic	4	01	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											20.00	40.00	60.00				10.00	20.00	6.00				20.00				20.00			0.67	0.33		0.67	0.33	0.67	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	6.00	20.00		20.00
S5617	279	0		29	10	S5617_279_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.04	23	23	23				53.07	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	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.43	50	50	50				34.80	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	4			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	4			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					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	0.30	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
S5617	348	0		29	10	S5617_348_0	4			Generic	2	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					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	3.00				20.00				20.00			0.67	0.10		0.67	0.10	0.67	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	3.00	20.00		20.00
S5617	348	0		29	10	S5617_348_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											60.70	23	23	23				54.55	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	348	0		29	10	S5617_348_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.90	50	50	50				36.89	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	348	0		29	10	S5617_348_0	4			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	4			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					1.00	2.00	3.00											7.00	14.00	21.00				1.00	2.00	0.00				7.00				7.00			0.23	0.03		0.23	0.03	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00	14.00	21.00	1.00	2.00	3.00	7.00	14.00	21.00	1.00	2.00	0.00	7.00		7.00
S5617	349	0		29	10	S5617_349_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								14.00	28.00	42.00					6.00	12.00	18.00											14.00	28.00	42.00				6.00	12.00	4.00				14.00				14.00			0.47	0.20		0.47	0.20	0.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00	6.00	12.00	18.00	14.00	28.00	42.00	6.00	12.00	4.00	14.00		14.00
S5617	349	0		29	10	S5617_349_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.19	20	20	20				41.02	16	16	16										20	20	20				16	16	16			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	349	0		29	10	S5617_349_0	4			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.66	41	41	41				30.26	41	41	41										41	41	41				41	41	41			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
S5617	349	0		29	10	S5617_349_0	4			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	4			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					0.00	0.00	0.00											11.00	22.00	33.00				0.00	0.00	0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	0.00	0.00	0.00	11.00	22.00	33.00	0.00	0.00	0.00	11.00		11.00
S5617	351	0		29	10	S5617_351_0	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	4.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	4.00	20.00		20.00
S5617	351	0		29	10	S5617_351_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.00	25	25	25				48.12	19	19	19										25	25	25				19	19	19			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
S5617	351	0		29	10	S5617_351_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											72.15	50	50	50				41.09	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	352	0		29	10	S5617_352_0	4			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
S5617	352	0		29	10	S5617_352_0	4			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	3.00				15.00				15.00			0.50	0.17		0.50	0.17	0.50	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	3.00	15.00		15.00
S5617	352	0		29	10	S5617_352_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.31	21	21	21				47.29	18	18	18										21	21	21				18	18	18			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	352	0		29	10	S5617_352_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											60.81	50	50	50				44.84	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	352	0		29	10	S5617_352_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	353	0		29	10	S5617_353_0	4			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	0.20	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										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
S5617	353	0		29	10	S5617_353_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								13.00	26.00	39.00					5.00	10.00	15.00											13.00	26.00	39.00				5.00	10.00	3.00				13.00				13.00			0.43	0.17		0.43	0.17	0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										13.00	26.00	39.00	5.00	10.00	15.00	13.00	26.00	39.00	5.00	10.00	3.00	13.00		13.00
S5617	353	0		29	10	S5617_353_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.18	20	20	20				40.14	16	16	16										20	20	20				16	16	16			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	353	0		29	10	S5617_353_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.90	42	42	42				43.76	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	353	0		29	10	S5617_353_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	354	0		29	10	S5617_354_0	4			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
S5617	354	0		29	10	S5617_354_0	4			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	3.00				15.00				15.00			0.50	0.17		0.50	0.17	0.50	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	3.00	15.00		15.00
S5617	354	0		29	10	S5617_354_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.10	20	20	20				40.13	17	17	17										20	20	20				17	17	17			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	354	0		29	10	S5617_354_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.09	46	46	46				46.76	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	354	0		29	10	S5617_354_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	355	0		29	10	S5617_355_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.33	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	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	4.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	4.00	20.00		20.00
S5617	355	0		29	10	S5617_355_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.08	21	21	21				37.41	17	17	17										21	21	21				17	17	17			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	355	0		29	10	S5617_355_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											68.02	50	50	50				42.51	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
S5617	355	0		29	10	S5617_355_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	356	0		29	10	S5617_356_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											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.30	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
S5617	356	0		29	10	S5617_356_0	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	3.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	3.00	20.00		20.00
S5617	356	0		29	10	S5617_356_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.25	21	21	21				46.86	18	18	18										21	21	21				18	18	18			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	356	0		29	10	S5617_356_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.58	50	50	50				46.62	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	356	0		29	10	S5617_356_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	357	0		29	10	S5617_357_0	4			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
S5617	357	0		29	10	S5617_357_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	357	0		29	10	S5617_357_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.66	20	20	20				36.58	17	17	17										20	20	20				17	17	17			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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											48.31	48	48	48				41.78	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	357	0		29	10	S5617_357_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	358	0		29	10	S5617_358_0	4			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	0.27	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
S5617	358	0		29	10	S5617_358_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	358	0		29	10	S5617_358_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.58	20	20	20				41.38	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	358	0		29	10	S5617_358_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.04	50	50	50				42.62	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	358	0		29	10	S5617_358_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	359	0		29	10	S5617_359_0	4			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
S5617	359	0		29	10	S5617_359_0	4			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	3.00				15.00				15.00			0.50	0.17		0.50	0.17	0.50	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	3.00	15.00		15.00
S5617	359	0		29	10	S5617_359_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.22	20	20	20				39.84	17	17	17										20	20	20				17	17	17			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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.52	50	50	50				38.86	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	360	0		29	10	S5617_360_0	4			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
S5617	360	0		29	10	S5617_360_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	360	0		29	10	S5617_360_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.18	20	20	20				39.25	17	17	17										20	20	20				17	17	17			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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.89	48	48	48				40.71	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	360	0		29	10	S5617_360_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	361	0		29	10	S5617_361_0	4			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	0.27	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
S5617	361	0		29	10	S5617_361_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					5.00	10.00	15.00											17.00	34.00	51.00				5.00	10.00	3.00				17.00				17.00			0.57	0.17		0.57	0.17	0.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										17.00	34.00	51.00	5.00	10.00	15.00	17.00	34.00	51.00	5.00	10.00	3.00	17.00		17.00
S5617	361	0		29	10	S5617_361_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.33	20	20	20				43.25	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	361	0		29	10	S5617_361_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.65	50	50	50				41.67	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	362	0		29	10	S5617_362_0	4			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	0.27	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
S5617	362	0		29	10	S5617_362_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	362	0		29	10	S5617_362_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.29	20	20	20				37.38	17	17	17										20	20	20				17	17	17			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	362	0		29	10	S5617_362_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.70	50	50	50				42.89	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	362	0		29	10	S5617_362_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	363	0		29	10	S5617_363_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											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.30	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
S5617	363	0		29	10	S5617_363_0	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	3.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	3.00	20.00		20.00
S5617	363	0		29	10	S5617_363_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.81	23	23	23				44.82	18	18	18										23	23	23				18	18	18			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	363	0		29	10	S5617_363_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											59.99	50	50	50				37.89	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	363	0		29	10	S5617_363_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	364	0		29	10	S5617_364_0	4			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
S5617	364	0		29	10	S5617_364_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	364	0		29	10	S5617_364_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											50.28	24	24	24				45.87	18	18	18										24	24	24				18	18	18			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
S5617	364	0		29	10	S5617_364_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											65.04	50	50	50				48.24	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	364	0		29	10	S5617_364_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	365	0		29	10	S5617_365_0	4			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	0.27	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
S5617	365	0		29	10	S5617_365_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					5.00	10.00	15.00											17.00	34.00	51.00				5.00	10.00	3.00				17.00				17.00			0.57	0.17		0.57	0.17	0.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										17.00	34.00	51.00	5.00	10.00	15.00	17.00	34.00	51.00	5.00	10.00	3.00	17.00		17.00
S5617	365	0		29	10	S5617_365_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.93	21	21	21				37.43	17	17	17										21	21	21				17	17	17			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	365	0		29	10	S5617_365_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.55	50	50	50				39.27	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	366	0		29	10	S5617_366_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.33	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	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	4.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	4.00	20.00		20.00
S5617	366	0		29	10	S5617_366_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											48.05	25	25	25				46.18	19	19	19										25	25	25				19	19	19			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
S5617	366	0		29	10	S5617_366_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.65	50	50	50				44.85	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	367	0		29	10	S5617_367_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.33	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	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	4.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	4.00	20.00		20.00
S5617	367	0		29	10	S5617_367_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.16	25	25	25				43.10	19	19	19										25	25	25				19	19	19			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
S5617	367	0		29	10	S5617_367_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											63.46	50	50	50				41.54	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	368	0		29	10	S5617_368_0	4			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
S5617	368	0		29	10	S5617_368_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	368	0		29	10	S5617_368_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.79	21	21	21				44.32	19	19	19										21	21	21				19	19	19			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	368	0		29	10	S5617_368_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.03	50	50	50				38.37	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	369	0		29	10	S5617_369_0	4			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	0.27	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
S5617	369	0		29	10	S5617_369_0	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	3.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	3.00	20.00		20.00
S5617	369	0		29	10	S5617_369_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											46.52	22	22	22				39.16	17	17	17										22	22	22				17	17	17			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.02	50	50	50				31.41	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	370	0		29	10	S5617_370_0	4			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	0.27	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
S5617	370	0		29	10	S5617_370_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					5.00	10.00	15.00											17.00	34.00	51.00				5.00	10.00	3.00				17.00				17.00			0.57	0.17		0.57	0.17	0.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										17.00	34.00	51.00	5.00	10.00	15.00	17.00	34.00	51.00	5.00	10.00	3.00	17.00		17.00
S5617	370	0		29	10	S5617_370_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.72	20	20	20				37.41	16	16	16										20	20	20				16	16	16			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	370	0		29	10	S5617_370_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.43	45	45	45				30.02	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
S5617	370	0		29	10	S5617_370_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	371	0		29	10	S5617_371_0	4			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	0.27	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
S5617	371	0		29	10	S5617_371_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	371	0		29	10	S5617_371_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.70	20	20	20				34.80	17	17	17										20	20	20				17	17	17			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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.71	47	47	47				26.58	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	371	0		29	10	S5617_371_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	372	0		29	10	S5617_372_0	4			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	0.27	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
S5617	372	0		29	10	S5617_372_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	372	0		29	10	S5617_372_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.19	20	20	20				37.51	17	17	17										20	20	20				17	17	17			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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.53	48	48	48				42.99	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	372	0		29	10	S5617_372_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	373	0		29	10	S5617_373_0	4			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	0.27	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
S5617	373	0		29	10	S5617_373_0	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	3.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	3.00	20.00		20.00
S5617	373	0		29	10	S5617_373_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.73	20	20	20				41.46	17	17	17										20	20	20				17	17	17			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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.51	50	50	50				32.92	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
S5617	373	0		29	10	S5617_373_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	374	0		29	10	S5617_374_0	4			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	0.27	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
S5617	374	0		29	10	S5617_374_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	374	0		29	10	S5617_374_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.94	20	20	20				34.14	17	17	17										20	20	20				17	17	17			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	374	0		29	10	S5617_374_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.16	45	45	45				30.18	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
S5617	374	0		29	10	S5617_374_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	375	0		29	10	S5617_375_0	4			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
S5617	375	0		29	10	S5617_375_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					5.00	10.00	15.00											17.00	34.00	51.00				5.00	10.00	3.00				17.00				17.00			0.57	0.17		0.57	0.17	0.57	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										17.00	34.00	51.00	5.00	10.00	15.00	17.00	34.00	51.00	5.00	10.00	3.00	17.00		17.00
S5617	375	0		29	10	S5617_375_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.43	23	23	23				46.42	18	18	18										23	23	23				18	18	18			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	375	0		29	10	S5617_375_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.79	50	50	50				37.14	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
S5617	375	0		29	10	S5617_375_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	376	0		29	10	S5617_376_0	4			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
S5617	376	0		29	10	S5617_376_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	376	0		29	10	S5617_376_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.93	20	20	20				42.22	17	17	17										20	20	20				17	17	17			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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											59.10	47	47	47				42.34	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	376	0		29	10	S5617_376_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	377	0		29	10	S5617_377_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.33	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	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	3.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	3.00	20.00		20.00
S5617	377	0		29	10	S5617_377_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.27	24	24	24				44.10	18	18	18										24	24	24				18	18	18			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
S5617	377	0		29	10	S5617_377_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.54	50	50	50				41.08	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	377	0		29	10	S5617_377_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	378	0		29	10	S5617_378_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											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.30	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
S5617	378	0		29	10	S5617_378_0	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	3.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	3.00	20.00		20.00
S5617	378	0		29	10	S5617_378_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.09	25	25	25				36.22	17	17	17										25	25	25				17	17	17			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
S5617	378	0		29	10	S5617_378_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.55	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										35.00	70.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	379	0		29	10	S5617_379_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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.33	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	4			Generic	4	01	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											20.00	40.00	60.00				5.00	10.00	4.00				20.00				20.00			0.67	0.17		0.67	0.17	0.67	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	4.00	20.00		20.00
S5617	379	0		29	10	S5617_379_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.37	21	21	21				43.26	18	18	18										21	21	21				18	18	18			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	379	0		29	10	S5617_379_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.07	50	50	50				40.92	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
S5617	379	0		29	10	S5617_379_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	380	0		29	10	S5617_380_0	4			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
S5617	380	0		29	10	S5617_380_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								18.00	36.00	54.00					5.00	10.00	15.00											18.00	36.00	54.00				5.00	10.00	3.00				18.00				18.00			0.60	0.17		0.60	0.17	0.60	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										18.00	36.00	54.00	5.00	10.00	15.00	18.00	36.00	54.00	5.00	10.00	3.00	18.00		18.00
S5617	380	0		29	10	S5617_380_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.31	25	25	25				46.20	19	19	19										25	25	25				19	19	19			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
S5617	380	0		29	10	S5617_380_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.49	50	50	50				39.85	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	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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	381	0		29	10	S5617_381_0	4			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	0.27	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
S5617	381	0		29	10	S5617_381_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								18.00	36.00	54.00					5.00	10.00	15.00											18.00	36.00	54.00				5.00	10.00	3.00				18.00				18.00			0.60	0.17		0.60	0.17	0.60	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										18.00	36.00	54.00	5.00	10.00	15.00	18.00	36.00	54.00	5.00	10.00	3.00	18.00		18.00
S5617	381	0		29	10	S5617_381_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.30	22	22	22				41.17	18	18	18										22	22	22				18	18	18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	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	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.11	50	50	50				32.22	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	105.00	35.00		35.00
S5617	381	0		29	10	S5617_381_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										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								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
S5617	382	0		29	10	S5617_382_0	5			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					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	3.00				15.00				15.00			0.50	0.17		0.50	0.17	0.50	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	3.00	15.00		15.00
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											35.82	20	20	20				38.15	17	17	17										20	20	20				17	17	17			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	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											55.39	41	41	41				39.95	41	41	41										41	41	41				41	41	41			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
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	4			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
S5617	383	0		29	10	S5617_383_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								14.00	28.00	42.00					5.00	10.00	15.00											14.00	28.00	42.00				5.00	10.00	3.00				14.00				14.00			0.47	0.17		0.47	0.17	0.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00	5.00	10.00	15.00	14.00	28.00	42.00	5.00	10.00	3.00	14.00		14.00
S5617	383	0		29	10	S5617_383_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.37	20	20	20				47.59	17	17	17										20	20	20				17	17	17			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	383	0		29	10	S5617_383_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.05	43	43	43				44.88	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	383	0		29	10	S5617_383_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	384	0		29	10	S5617_384_0	4			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
S5617	384	0		29	10	S5617_384_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								14.00	28.00	42.00					5.00	10.00	15.00											14.00	28.00	42.00				5.00	10.00	3.00				14.00				14.00			0.47	0.17		0.47	0.17	0.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										14.00	28.00	42.00	5.00	10.00	15.00	14.00	28.00	42.00	5.00	10.00	3.00	14.00		14.00
S5617	384	0		29	10	S5617_384_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.66	20	20	20				43.01	17	17	17										20	20	20				17	17	17			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	384	0		29	10	S5617_384_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.87	43	43	43				42.19	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	384	0		29	10	S5617_384_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										35.00			35.00			35.00			35.00			35.00		35.00
S5617	385	0		29	10	S5617_385_0	4			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	0.27	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
S5617	385	0		29	10	S5617_385_0	4			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					5.00	10.00	15.00											16.00	32.00	48.00				5.00	10.00	3.00				16.00				16.00			0.53	0.17		0.53	0.17	0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										16.00	32.00	48.00	5.00	10.00	15.00	16.00	32.00	48.00	5.00	10.00	3.00	16.00		16.00
S5617	385	0		29	10	S5617_385_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.92	20	20	20				39.70	17	17	17										20	20	20				17	17	17			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	385	0		29	10	S5617_385_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.25	47	47	47				41.59	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	385	0		29	10	S5617_385_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										35.00			35.00			35.00			35.00			35.00		35.00
S5715	001	0		29	10	S5715_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								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			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											95.43	50	50	50				98.61	39	39	39										50	50	50				39	39	39			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	001	0		29	10	S5715_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											493.58	25						382.20	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	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					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			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								44.00	88.00	132.00					42.00	84.00	126.00											44.00	88.00	132.00				42.00	84.00	126.00				44.00				44.00			1.47	1.40		1.47	1.40	1.42	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
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											96.58	50	50	50				97.80	44	44	44										50	50	50				44	44	44			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	003	0		29	10	S5715_003_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											580.24	25						406.65	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	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					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			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								35.00	70.00	105.00					33.00	66.00	99.00											35.00	70.00	105.00				33.00	66.00	99.00				35.00				35.00			1.17	1.10		1.17	1.10	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00	70.00	105.00	33.00	66.00	99.00	35.00	70.00	105.00	33.00	66.00	99.00	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											92.76	50	50	50				99.87	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
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											499.57	25						381.87	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	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					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			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											95.39	50	50	50				98.89	47	47	47										50	50	50				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	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											486.96	25						567.35	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	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					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	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								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
S5715	012	0		29	10	S5715_012_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.56	20	20	20				49.33	20	20	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	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											79.94	50	50	50				80.45	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
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											499.62	25						358.64	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	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					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	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								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
S5715	013	0		29	10	S5715_013_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.00	19	19	19				44.08	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
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											84.96	48	48	48				93.63	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
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											580.71	25						436.84	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	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					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	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								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
S5715	014	0		29	10	S5715_014_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.94	18	18	18				43.83	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
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											74.33	50	50	50				82.98	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
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											497.34	25						355.53	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	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					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								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
S5715	015	0		29	10	S5715_015_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.50	17	17	17				41.02	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
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											65.12	48	48	48				75.84	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
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											443.64	25						457.61	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5715	018	0		29	10	S5715_018_0	5			Preferred Generic	4	11	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	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					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	018	0		29	10	S5715_018_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.30	17	17	17				40.10	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
S5715	018	0		29	10	S5715_018_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											65.83	40	40	40				97.89	36	36	36										40	40	40				36	36	36			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	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											552.52	25						337.82	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5715	019	0		29	10	S5715_019_0	5			Preferred Generic	4	11	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	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					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	019	0		29	10	S5715_019_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.8	21	21	21				56.33	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	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	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.09	44	44	44				97.61	30	30	30										44	44	44				30	30	30			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
S5715	019	0		29	10	S5715_019_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.48	25						386.68	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5715	020	0		29	10	S5715_020_0	5			Preferred Generic	4	11	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	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					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	020	0		29	10	S5715_020_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.72	17	17	17				43.42	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
S5715	020	0		29	10	S5715_020_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											85.93	41	41	41				86.02	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
S5715	020	0		29	10	S5715_020_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											625.84	25						335.93	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	11	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					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	021	0		29	10	S5715_021_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.46	17	17	17				42.22	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
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											76.77	40	40	40				85.42	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
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											494.79	25						336.36	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5726	013	0		29	10	S5726_013_0	1			Preferred Generic	3	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											7.00	14.00	21.00				2.00	4.00	6.00				7.00				7.00			0.23	0.07		0.23	0.07	0.21	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	6.00	7.00		7.00
S5726	013	0		29	10	S5726_013_0	1			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		34								9.00	18.00	27.00					4.00	8.00	12.00											9.00	18.00	27.00				4.00	8.00	12.00				9.00				9.00			0.30	0.13		0.30	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										9.00	18.00	27.00	4.00	8.00	12.00	9.00	18.00	27.00	4.00	8.00	12.00	9.00		9.00
S5726	013	0		29	10	S5726_013_0	1			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											69.75	25	25	25				54.41	20	20	20										25	25	25				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	70.00	105.00	35.00		35.00
S5726	013	0		29	10	S5726_013_0	1			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											69.10	50	50	50				65.57	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
S5726	013	0		29	10	S5726_013_0	1			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		34											345.03	25						315.58	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5726	014	0		29	10	S5726_014_0	2			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											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.15	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
S5726	014	0		29	10	S5726_014_0	2			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34								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	0.21	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
S5726	014	0		29	10	S5726_014_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											68.43	25	25	25				53.90	20	20	20										25	25	25				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	70.00	105.00	35.00		35.00
S5726	014	0		29	10	S5726_014_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											72.53	50	50	50				54.02	40	40	40										50	50	50				40	40	40			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
S5726	014	0		29	10	S5726_014_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		34											580.87	33						544.95	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5726	020	0		29	10	S5726_020_0	2			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	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	0.15	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		5.00
S5726	020	0		29	10	S5726_020_0	2			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34								7.00	14.00	14.00					2.00	4.00	4.00											7.00	14.00	14.00				2.00	4.00	4.00				7.00				7.00			0.23	0.07		0.23	0.07	0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										7.00	14.00	14.00	2.00	4.00	4.00	7.00	14.00	14.00	2.00	4.00	4.00	7.00		7.00
S5726	020	0		29	10	S5726_020_0	2			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											96.16	25	25	25				77.77	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
S5726	020	0		29	10	S5726_020_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											89.71	50	50	50				89.12	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
S5726	020	0		29	10	S5726_020_0	2			Specialty Tier	4	10	1	1	5	1		010	01		010	1				30								30			30		34											351.60	27						385.01	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5743	001	0		29	10	S5743_001_0	1			Preferred Generic	2	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										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
S5743	001	0		29	10	S5743_001_0	1			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	6.00				11.00				11.00			0.37	0.07		0.37	0.07	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										11.00	22.00	33.00	2.00	4.00	6.00	11.00	22.00	33.00	2.00	4.00	6.00	11.00		11.00
S5743	001	0		29	10	S5743_001_0	1			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.64	25	25	25				61.18	23	23	23										25	25	25				23	23	23			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	001	0		29	10	S5743_001_0	1			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											60.56	50	50	50				50.29	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
S5743	001	0		29	10	S5743_001_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											408.75	25						393.13	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5743	004	0		29	10	S5743_004_0	1			Preferred Generic	4	11	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	1			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	1			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.87	25	25	25				40.89	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
S5743	004	0		29	10	S5743_004_0	1			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											60.30	45	45	45				50.11	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	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											414.13	33						373.64	33												33						33					33			33								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			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			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	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				98.60	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		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				594.34	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	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																								
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	15.00		45.00																			15.00		45.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5795	003	0		29	10	S5795_003_0	1			Preferred Brand	3	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				56.35	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
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				99.77	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		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				194.17	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
S5884	101	0		29	10	S5884_101_0	2			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	2			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	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				43.00	22		22																								22		22				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
S5884	101	0		29	10	S5884_101_0	2			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				71.00	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		35.00
S5884	101	0		29	10	S5884_101_0	2			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				47.00	22		22																								22		22				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
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				74.00	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		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		23			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				71.00	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		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				48.00	23		23																								23		23				23		23			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				66.00	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		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				52.00	23		23																								23		23				23		23			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	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				69.00	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		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				45.00	22		22																								22		22				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
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				75.00	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		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	1.00		1.00
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				51.00	24		24																								24		24				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
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				56.00	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		35.00
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			35.00		35.00
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				49.00	22		22																								22		22				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
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				90.00	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		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	1.00		1.00
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				41.00	23		23																								23		23				23		23			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	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				54.00	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
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			35.00		35.00
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				53.00	23		23																								23		23				23		23			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	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				70.00	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		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	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
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				89.00	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		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	1.00		1.00
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				54.00	23		23																								23		23				23		23			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	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				75.00	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		35.00
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			35.00		35.00
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				52.00	23		23																								23		23				23		23			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	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				70.00	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		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				51.00	22		22																								22		22				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
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				79.00	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		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	4.00		12.00																									4.00		12.00				4.00		0.00				4.00				4.00		0.13				0.13	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										4.00		12.00				4.00		12.00	4.00		0.00	4.00		4.00
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				53.00	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
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				72.00	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		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				55.00	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
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				81.00	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		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	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
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	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		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				47.00	22		22																								22		22				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
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				79.00	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		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	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
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				90.00	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		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				51.00	23		23																								23		23				23		23			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				59.00	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		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				46.00	22		22																								22		22				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
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				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		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				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
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				84.00	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		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	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	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				52.00	23		23																								23		23				23		23			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	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				66.00	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		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				48.00	24		24																								24		24				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
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				53.00	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		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				46.00	22		22																								22		22				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
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				79.00	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		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				40.00	23		23																								23		23				23		23			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	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				58.00	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		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				46.00	23		23																								23		23				23		23			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				65.00	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		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				47.00	22		22																								22		22				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
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				78.00	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		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				48.00	23		23																								23		23				23		23			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	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				65.00	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		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				49.00	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
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				88.00	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		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				44.00	23		23																								23		23				23		23			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				61.00	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		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				52.00	22		22																								22		22				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
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				65.00	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		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				45.00	22		22																								22		22				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
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				75.00	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		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	2			Preferred Generic	4	11	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		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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
S5884	148	0		29	10	S5884_148_0	2			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										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	2			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										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	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											57.00	50		50				40.00	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	148	0		29	10	S5884_148_0	2			Specialty Tier	4	11	1	1	5	1		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
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											57.00	50		50				49.00	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	149	0		29	10	S5884_149_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											61.00	50		50				47.00	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	150	0		29	10	S5884_150_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											58.00	50		50				50.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											55.00	50		50				48.00	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	152	0		29	10	S5884_152_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											52.00	50		50				45.00	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	153	0		29	10	S5884_153_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											58.00	50		50				48.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											57.00	50		50				46.00	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	155	0		29	10	S5884_155_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											58.00	50		50				51.00	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	156	0		29	10	S5884_156_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											63.00	50		50				46.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											58.00	50		50				49.00	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	158	0		29	10	S5884_158_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											54.00	50		50				47.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											59.00	50		50				45.00	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	160	0		29	10	S5884_160_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											55.00	50		50				49.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											56.00	50		50				42.00	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	162	0		29	10	S5884_162_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											53.00	50		50				48.00	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	163	0		29	10	S5884_163_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											50.00	50		50				46.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											53.00	50		50				51.00	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	165	0		29	10	S5884_165_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											52.00	50		50				46.00	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	166	0		29	10	S5884_166_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											55.00	50		50				49.00	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	167	0		29	10	S5884_167_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											59.00	50		50				54.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											59.00	50		50				49.00	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	169	0		29	10	S5884_169_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											52.00	50		50				44.00	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	170	0		29	10	S5884_170_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											50.00	50		50				48.00	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	171	0		29	10	S5884_171_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											60.00	50		50				61.00	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	172	0		29	10	S5884_172_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											57.00	50		50				50.00	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	173	0		29	10	S5884_173_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											62.00	50		50				50.00	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	174	0		29	10	S5884_174_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											70.00	50		50				47.00	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	175	0		29	10	S5884_175_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											50.00	50		50				42.00	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	176	0		29	10	S5884_176_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											51.00	50		50				44.00	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	177	0		29	10	S5884_177_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											63.00	50		50				52.00	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	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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											62.00	50		50				57.00	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	179	0		29	10	S5884_179_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										35.00			35.00			35.00			35.00			35.00		35.00
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					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										5.00		15.00	0.00		0.00	5.00		15.00	0.00		0.00	5.00		5.00
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										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			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										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											65.00	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
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												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
S5884	181	0		29	10	S5884_181_0	2			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
S5884	181	0		29	10	S5884_181_0	2			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
S5884	181	0		29	10	S5884_181_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											37.00	20		20				51.00	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		105.00	35.00		35.00
S5884	181	0		29	10	S5884_181_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											45.00	35		35				36.00	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		105.00	35.00		105.00	35.00		35.00
S5884	181	0		29	10	S5884_181_0	2			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										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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											36.00	18		18				43.00	18		18										18		18				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		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											46.00	34		34				39.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
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											39.00	19		19				47.00	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		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											51.00	35		35				43.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											40.00	20		20				48.00	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		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											45.00	35		35				41.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											39.00	20		20				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		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											46.00	35		35				37.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											41.00	20		20				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		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											44.00	34		34				36.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											40.00	20		20				43.00	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		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											44.00	34		34				34.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											39.00	19		19				39.00	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		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											51.00	34		34				35.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											38.00	20		20				40.00	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		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											46.00	34		34				37.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											40.00	20		20				41.00	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		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											48.00	34		34				34.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											37.00	20		20				41.00	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		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											46.00	34		34				35.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											41.00	20		20				50.00	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		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											47.00	35		35				40.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
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											40.00	20		20				44.00	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		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											44.00	34		34				36.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
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											39.00	20		20				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		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											43.00	34		34				37.00	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		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												26							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
S5884	195	0		29	10	S5884_195_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
S5884	195	0		29	10	S5884_195_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
S5884	195	0		29	10	S5884_195_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											42.00	20		20				48.00	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		105.00	35.00		35.00
S5884	195	0		29	10	S5884_195_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											46.00	35		35				38.00	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		105.00	35.00		105.00	35.00		35.00
S5884	195	0		29	10	S5884_195_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										35.00			35.00			35.00			35.00			35.00		35.00
S5884	196	0		29	10	S5884_196_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
S5884	196	0		29	10	S5884_196_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
S5884	196	0		29	10	S5884_196_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											41.00	20		20				48.00	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		105.00	35.00		35.00
S5884	196	0		29	10	S5884_196_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											43.00	35		35				43.00	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		105.00	35.00		105.00	35.00		35.00
S5884	196	0		29	10	S5884_196_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										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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											36.00	20		20				44.00	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		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											41.00	35		35				36.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											40.00	20		20				44.00	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		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											48.00	35		35				38.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											45.00	20		20				40.00	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		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											45.00	34		34				37.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											34.00	20		20				41.00	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		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											41.00	34		34				30.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											39.00	20		20				44.00	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		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											51.00	34		34				39.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											45.00	20		20				48.00	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		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											45.00	34		34				36.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											39.00	20		20				42.00	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		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											39.00	35		35				33.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											43.00	20		20				49.00	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		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											44.00	35		35				36.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											44.00	20		20				40.00	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		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											45.00	33		33				37.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
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											41.00	20		20				49.00	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		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											49.00	34		34				37.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											42.00	20		20				46.00	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		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											50.00	35		35				39.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								3.00		9.00					0.00		0.00											3.00		9.00				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		9.00	0.00		0.00	3.00		9.00	0.00		0.00	3.00		3.00
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											36.00	18		18				45.00	18		18										18		18				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		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											59.00	35		35				49.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											41.00	20		20				44.00	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		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											42.00	35		35				35.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								4.00		12.00					0.00		0.00											4.00		12.00				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		12.00	0.00		0.00	4.00		12.00	0.00		0.00	4.00		4.00
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											43.00	20		20				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		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											42.00	35		35				31.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
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											38.00	18		18				40.00	18		18										18		18				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		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											53.00	35		35				37.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
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											46.00	20		20				51.00	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		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											45.00	34		34				43.00	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		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												26							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
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								1.00		3.00					0.00		0.00											1.00		3.00				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										1.00		3.00	0.00		0.00	1.00		3.00	0.00		0.00	1.00		1.00
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								2.00		6.00					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
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											48.00	20		20				55.00	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		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											48.00	34		34				46.00	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		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												26							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
S5884	214	0		29	10	S5884_214_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	214	0		29	10	S5884_214_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	214	0		29	10	S5884_214_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		23			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	214	0		29	10	S5884_214_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				68.00	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		35.00
S5884	214	0		29	10	S5884_214_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	215	0		29	10	S5884_215_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					0.00		0.00											2.00		6.00				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		6.00	0.00		0.00	2.00		6.00	0.00		0.00	2.00		2.00
S5884	215	0		29	10	S5884_215_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										4.00		12.00	2.00		6.00	4.00		12.00	2.00		0.00	4.00		4.00
S5884	215	0		29	10	S5884_215_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										25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	215	0		29	10	S5884_215_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				42.00	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	215	0		29	10	S5884_215_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										35.00			35.00			35.00			35.00			35.00		35.00
S5904	001	0		29	10	S5904_001_0	6			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	6			Generic	3	01	1	2	2	1	110		01	110		1	31		90				1	2	31		90				31		31	17.00		51.00																			17.00		51.00																17.00				17.00		0.55			0.55			0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5904	001	0		29	10	S5904_001_0	6			Preferred Brand	3	10	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				43.14	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
S5904	001	0		29	10	S5904_001_0	6			Non-Preferred Drug	3	10	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				36.76	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	6			Specialty Tier	3	10	1	1	5	1	010		01	010		1	31								31						31		31				118.66	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	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	1	31		90				31		31				45.69	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
S5904	002	0		29	10	S5904_002_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	1	31		90				31		31				38.61	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
S5904	002	0		29	10	S5904_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				111.86	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00						35.00						35.00		35.00
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											30.00	16		16				35.00	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	348	0		29	10	S5921_348_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	45						54.00	42												45						42					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			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											373.00	25						358.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	349	0		29	10	S5921_349_0	4			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	4			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	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											33.00	16		16				38.00	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	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											57.00	47						60.00	44												47						44					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	349	0		29	10	S5921_349_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											337.00	25						354.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	350	0		29	10	S5921_350_0	4			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	4			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	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	17		17				40.00	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	350	0		29	10	S5921_350_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	46						51.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	350	0		29	10	S5921_350_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											381.00	25						362.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	351	0		29	10	S5921_351_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	351	0		29	10	S5921_351_0	3			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	351	0		29	10	S5921_351_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	17		17				38.00	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	351	0		29	10	S5921_351_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											47.00	43						42.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	351	0		29	10	S5921_351_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											370.00	25						353.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	352	0		29	10	S5921_352_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	352	0		29	10	S5921_352_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	352	0		29	10	S5921_352_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											30.00	17		17				37.00	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	352	0		29	10	S5921_352_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											47.00	46						45.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	352	0		29	10	S5921_352_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											390.00	25						354.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	353	0		29	10	S5921_353_0	4			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	4			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	353	0		29	10	S5921_353_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											35.00	17		17				37.00	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	353	0		29	10	S5921_353_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											51.00	45						50.00	42												45						42					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	353	0		29	10	S5921_353_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											348.00	25						354.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	354	0		29	10	S5921_354_0	4			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	354	0		29	10	S5921_354_0	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	354	0		29	10	S5921_354_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											33.00	17		17				38.00	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	354	0		29	10	S5921_354_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	46						58.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	354	0		29	10	S5921_354_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											331.00	25						333.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	355	0		29	10	S5921_355_0	4			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	355	0		29	10	S5921_355_0	4			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	355	0		29	10	S5921_355_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	17		17				39.00	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	355	0		29	10	S5921_355_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											53.00	47						51.00	44												47						44					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	355	0		29	10	S5921_355_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											371.00	25						358.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	356	0		29	10	S5921_356_0	4			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	4			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	356	0		29	10	S5921_356_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	17		17				38.00	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	356	0		29	10	S5921_356_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											51.00	47						57.00	44												47						44					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	356	0		29	10	S5921_356_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											391.00	25						370.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	357	0		29	10	S5921_357_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	357	0		29	10	S5921_357_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	357	0		29	10	S5921_357_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	16		16				32.00	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	357	0		29	10	S5921_357_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											48.00	48						50.00	45												48						45					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	357	0		29	10	S5921_357_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											387.00	25						353.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	358	0		29	10	S5921_358_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	358	0		29	10	S5921_358_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	358	0		29	10	S5921_358_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											30.00	17		17				39.00	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	358	0		29	10	S5921_358_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											46.00	46						41.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	358	0		29	10	S5921_358_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											367.00	25						351.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	359	0		29	10	S5921_359_0	4			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	359	0		29	10	S5921_359_0	4			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	359	0		29	10	S5921_359_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											34.00	18		18				41.00	18		18												18						18			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
S5921	359	0		29	10	S5921_359_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											41.00	43						43.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	359	0		29	10	S5921_359_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											330.00	25						314.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	360	0		29	10	S5921_360_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	360	0		29	10	S5921_360_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	17		17				36.00	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	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	46						49.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	360	0		29	10	S5921_360_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											356.00	25						361.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	361	0		29	10	S5921_361_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	361	0		29	10	S5921_361_0	3			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	361	0		29	10	S5921_361_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	16		16				32.00	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	361	0		29	10	S5921_361_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	43						49.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	361	0		29	10	S5921_361_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											377.00	25						322.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	362	0		29	10	S5921_362_0	4			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	4			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	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				37.00	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	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	48						51.00	45												48						45					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	362	0		29	10	S5921_362_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											396.00	25						355.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	363	0		29	10	S5921_363_0	4			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	4			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	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	17		17				34.00	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	363	0		29	10	S5921_363_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											38.00	43						46.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	363	0		29	10	S5921_363_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											387.00	25						327.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	364	0		29	10	S5921_364_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	364	0		29	10	S5921_364_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	17		17				34.00	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	364	0		29	10	S5921_364_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											42.00	45						40.00	42												45						42					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	364	0		29	10	S5921_364_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											348.00	25						321.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	365	0		29	10	S5921_365_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					6.00		18.00													27.00						18.00				9.00				9.00			0.30	0.20				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	365	0		29	10	S5921_365_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				35.00	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	365	0		29	10	S5921_365_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	45						45.00	42												45						42					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	365	0		29	10	S5921_365_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											317.00	25						369.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	366	0		29	10	S5921_366_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	366	0		29	10	S5921_366_0	3			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					6.00		18.00													27.00						18.00				9.00				9.00			0.30	0.20				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	366	0		29	10	S5921_366_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	16		16				34.00	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	366	0		29	10	S5921_366_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	43						57.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	366	0		29	10	S5921_366_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											439.00	25						349.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	367	0		29	10	S5921_367_0	7			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	7			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	367	0		29	10	S5921_367_0	7			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	17		17				38.00	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	367	0		29	10	S5921_367_0	7			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											49.00	46						59.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	367	0		29	10	S5921_367_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											367.00	25						364.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	368	0		29	10	S5921_368_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	368	0		29	10	S5921_368_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				39.00	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	368	0		29	10	S5921_368_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											51.00	44						48.00	41												44						41					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	368	0		29	10	S5921_368_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											392.00	25						357.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	369	0		29	10	S5921_369_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	369	0		29	10	S5921_369_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				35.00	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	369	0		29	10	S5921_369_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											41.00	42						40.00	39												42						39					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	369	0		29	10	S5921_369_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											326.00	25						349.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	370	0		29	10	S5921_370_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	370	0		29	10	S5921_370_0	3			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	370	0		29	10	S5921_370_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	17		17				35.00	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	370	0		29	10	S5921_370_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											43.00	43						44.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	370	0		29	10	S5921_370_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											367.00	25						343.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	371	0		29	10	S5921_371_0	5			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	5			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					6.00		18.00													27.00						18.00				9.00				9.00			0.30	0.20				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	371	0		29	10	S5921_371_0	5			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	17		17				37.00	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	371	0		29	10	S5921_371_0	5			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											53.00	43						59.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	371	0		29	10	S5921_371_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											283.00	25						299.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	372	0		29	10	S5921_372_0	4			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	372	0		29	10	S5921_372_0	4			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	372	0		29	10	S5921_372_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	18		18				42.00	18		18												18						18			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
S5921	372	0		29	10	S5921_372_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	46						52.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	372	0		29	10	S5921_372_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											380.00	25						378.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	373	0		29	10	S5921_373_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					6.00		18.00													27.00						18.00				9.00				9.00			0.30	0.20				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	373	0		29	10	S5921_373_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	17		17				37.00	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	373	0		29	10	S5921_373_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											73.00	46						71.00	43												46						43					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	373	0		29	10	S5921_373_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											455.00	25						345.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	374	0		29	10	S5921_374_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	374	0		29	10	S5921_374_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	374	0		29	10	S5921_374_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	18		18				38.00	18		18												18						18			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
S5921	374	0		29	10	S5921_374_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	43						46.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	374	0		29	10	S5921_374_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											396.00	25						335.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	375	0		29	10	S5921_375_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	375	0		29	10	S5921_375_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	375	0		29	10	S5921_375_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				34.00	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	375	0		29	10	S5921_375_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											48.00	43						41.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	375	0		29	10	S5921_375_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											349.00	25						332.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	376	0		29	10	S5921_376_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	376	0		29	10	S5921_376_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	17		17				36.00	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	376	0		29	10	S5921_376_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											59.00	39						50.00	36												39						36					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	376	0		29	10	S5921_376_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											378.00	25						376.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	377	0		29	10	S5921_377_0	4			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	4			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	377	0		29	10	S5921_377_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	18		18				43.00	18		18												18						18			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
S5921	377	0		29	10	S5921_377_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											48.00	44						67.00	41												44						41					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	377	0		29	10	S5921_377_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											393.00	25						392.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	378	0		29	10	S5921_378_0	4			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	4			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								9.00		27.00					7.00		21.00													27.00						21.00				9.00				9.00			0.30	0.23				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	378	0		29	10	S5921_378_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	17		17				40.00	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	378	0		29	10	S5921_378_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											43.00	45						47.00	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
S5921	378	0		29	10	S5921_378_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											384.00	25						355.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	379	0		29	10	S5921_379_0	4			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	4			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	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											35.00	16		16				38.00	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	379	0		29	10	S5921_379_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											62.00	43						62.00	40												43						40					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	379	0		29	10	S5921_379_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											386.00	25						355.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	380	0		29	10	S5921_380_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	380	0		29	10	S5921_380_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	380	0		29	10	S5921_380_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											33.00	18		18				39.00	18		18												18						18			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
S5921	380	0		29	10	S5921_380_0	3			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											48.00	45						52.00	42												45						42					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	380	0		29	10	S5921_380_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											371.00	25						322.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	381	0		29	10	S5921_381_0	4			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	4			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	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											34.00	17		17				41.00	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	381	0		29	10	S5921_381_0	4			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	40						66.00	37												40						37					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	381	0		29	10	S5921_381_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											428.00	25						377.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	382	0		29	10	S5921_382_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	382	0		29	10	S5921_382_0	7			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	382	0		29	10	S5921_382_0	7			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
S5921	382	0		29	10	S5921_382_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											65.00	45						90.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	382	0		29	10	S5921_382_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											569.00	33						490.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	383	0		29	10	S5921_383_0	4			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	383	0		29	10	S5921_383_0	4			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	383	0		29	10	S5921_383_0	4			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
S5921	383	0		29	10	S5921_383_0	4			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											60.00	45						69.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	383	0		29	10	S5921_383_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											577.00	33						496.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	384	0		29	10	S5921_384_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	384	0		29	10	S5921_384_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	384	0		29	10	S5921_384_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
S5921	384	0		29	10	S5921_384_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	45						65.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	384	0		29	10	S5921_384_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											558.00	33						486.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	385	0		29	10	S5921_385_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	385	0		29	10	S5921_385_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	385	0		29	10	S5921_385_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
S5921	385	0		29	10	S5921_385_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											60.00	45						82.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	385	0		29	10	S5921_385_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											539.00	33						488.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	386	0		29	10	S5921_386_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	386	0		29	10	S5921_386_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	386	0		29	10	S5921_386_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
S5921	386	0		29	10	S5921_386_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											61.00	45						78.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	386	0		29	10	S5921_386_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											524.00	33						490.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	387	0		29	10	S5921_387_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	387	0		29	10	S5921_387_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	387	0		29	10	S5921_387_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
S5921	387	0		29	10	S5921_387_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											59.00	45						70.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	387	0		29	10	S5921_387_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											583.00	33						501.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	388	0		29	10	S5921_388_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	388	0		29	10	S5921_388_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	388	0		29	10	S5921_388_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
S5921	388	0		29	10	S5921_388_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	45						86.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	388	0		29	10	S5921_388_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											532.00	33						473.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	389	0		29	10	S5921_389_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	389	0		29	10	S5921_389_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	389	0		29	10	S5921_389_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
S5921	389	0		29	10	S5921_389_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	45						68.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	389	0		29	10	S5921_389_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											534.00	33						484.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	390	0		29	10	S5921_390_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	390	0		29	10	S5921_390_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	390	0		29	10	S5921_390_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
S5921	390	0		29	10	S5921_390_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	45						69.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	390	0		29	10	S5921_390_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											534.00	33						487.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	391	0		29	10	S5921_391_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	391	0		29	10	S5921_391_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	391	0		29	10	S5921_391_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
S5921	391	0		29	10	S5921_391_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											61.00	45						72.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	391	0		29	10	S5921_391_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											557.00	33						479.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	392	0		29	10	S5921_392_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	392	0		29	10	S5921_392_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	392	0		29	10	S5921_392_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
S5921	392	0		29	10	S5921_392_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											57.00	45						73.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	392	0		29	10	S5921_392_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											571.00	33						485.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	393	0		29	10	S5921_393_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	393	0		29	10	S5921_393_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	393	0		29	10	S5921_393_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
S5921	393	0		29	10	S5921_393_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	45						70.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	393	0		29	10	S5921_393_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											565.00	33						469.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	394	0		29	10	S5921_394_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	394	0		29	10	S5921_394_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	394	0		29	10	S5921_394_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
S5921	394	0		29	10	S5921_394_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											53.00	45						70.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	394	0		29	10	S5921_394_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											542.00	33						493.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	395	0		29	10	S5921_395_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	395	0		29	10	S5921_395_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	395	0		29	10	S5921_395_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
S5921	395	0		29	10	S5921_395_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											52.00	45						72.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	395	0		29	10	S5921_395_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											546.00	33						473.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	396	0		29	10	S5921_396_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	396	0		29	10	S5921_396_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	396	0		29	10	S5921_396_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
S5921	396	0		29	10	S5921_396_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	45						70.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	396	0		29	10	S5921_396_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											516.00	33						483.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	397	0		29	10	S5921_397_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	397	0		29	10	S5921_397_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	397	0		29	10	S5921_397_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
S5921	397	0		29	10	S5921_397_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	45						61.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	397	0		29	10	S5921_397_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											565.00	33						499.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	398	0		29	10	S5921_398_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	398	0		29	10	S5921_398_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	398	0		29	10	S5921_398_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
S5921	398	0		29	10	S5921_398_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	45						65.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	398	0		29	10	S5921_398_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											551.00	33						546.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	399	0		29	10	S5921_399_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	399	0		29	10	S5921_399_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	399	0		29	10	S5921_399_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
S5921	399	0		29	10	S5921_399_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											54.00	45						68.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	399	0		29	10	S5921_399_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											570.00	33						495.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	400	0		29	10	S5921_400_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	400	0		29	10	S5921_400_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	400	0		29	10	S5921_400_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
S5921	400	0		29	10	S5921_400_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											51.00	45						64.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	400	0		29	10	S5921_400_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											577.00	33						466.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	401	0		29	10	S5921_401_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	401	0		29	10	S5921_401_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	401	0		29	10	S5921_401_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
S5921	401	0		29	10	S5921_401_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											53.00	45						79.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	401	0		29	10	S5921_401_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											625.00	33						475.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	402	0		29	10	S5921_402_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	402	0		29	10	S5921_402_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	402	0		29	10	S5921_402_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
S5921	402	0		29	10	S5921_402_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											59.00	45						71.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	402	0		29	10	S5921_402_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											664.00	33						473.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	403	0		29	10	S5921_403_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	403	0		29	10	S5921_403_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	403	0		29	10	S5921_403_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
S5921	403	0		29	10	S5921_403_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											60.00	45						68.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	403	0		29	10	S5921_403_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											592.00	33						489.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	404	0		29	10	S5921_404_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	404	0		29	10	S5921_404_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	404	0		29	10	S5921_404_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
S5921	404	0		29	10	S5921_404_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											62.00	45						68.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	404	0		29	10	S5921_404_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											572.00	33						496.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	405	0		29	10	S5921_405_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	405	0		29	10	S5921_405_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	405	0		29	10	S5921_405_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
S5921	405	0		29	10	S5921_405_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											62.00	45						70.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	405	0		29	10	S5921_405_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											578.00	33						484.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	406	0		29	10	S5921_406_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	406	0		29	10	S5921_406_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	406	0		29	10	S5921_406_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
S5921	406	0		29	10	S5921_406_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	45						65.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	406	0		29	10	S5921_406_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											558.00	33						494.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	407	0		29	10	S5921_407_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	407	0		29	10	S5921_407_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	407	0		29	10	S5921_407_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
S5921	407	0		29	10	S5921_407_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											49.00	45						67.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	407	0		29	10	S5921_407_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											567.00	33						491.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	408	0		29	10	S5921_408_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	408	0		29	10	S5921_408_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	408	0		29	10	S5921_408_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
S5921	408	0		29	10	S5921_408_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											61.00	45						71.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	408	0		29	10	S5921_408_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											680.00	33						502.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	409	0		29	10	S5921_409_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	409	0		29	10	S5921_409_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	409	0		29	10	S5921_409_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
S5921	409	0		29	10	S5921_409_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											57.00	45						66.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	409	0		29	10	S5921_409_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											610.00	33						496.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	410	0		29	10	S5921_410_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	410	0		29	10	S5921_410_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	410	0		29	10	S5921_410_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
S5921	410	0		29	10	S5921_410_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											59.00	45						73.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	410	0		29	10	S5921_410_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											600.00	33						505.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	411	0		29	10	S5921_411_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	411	0		29	10	S5921_411_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	411	0		29	10	S5921_411_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
S5921	411	0		29	10	S5921_411_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											53.00	45						70.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	411	0		29	10	S5921_411_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											545.00	33						502.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	412	0		29	10	S5921_412_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	412	0		29	10	S5921_412_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	412	0		29	10	S5921_412_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
S5921	412	0		29	10	S5921_412_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	45						68.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	412	0		29	10	S5921_412_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											635.00	33						486.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	413	0		29	10	S5921_413_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	413	0		29	10	S5921_413_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	413	0		29	10	S5921_413_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
S5921	413	0		29	10	S5921_413_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											66.00	45						86.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	413	0		29	10	S5921_413_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											560.00	33						527.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	414	0		29	10	S5921_414_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	414	0		29	10	S5921_414_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	414	0		29	10	S5921_414_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
S5921	414	0		29	10	S5921_414_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											92.00	45						63.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	414	0		29	10	S5921_414_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											508.00	33						488.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	415	0		29	10	S5921_415_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								13.00		39.00					5.00		15.00													39.00						0.00				13.00				13.00			0.43	0.16				0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	415	0		29	10	S5921_415_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								18.00		54.00					10.00		30.00													54.00						0.00				18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5921	415	0		29	10	S5921_415_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
S5921	415	0		29	10	S5921_415_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	45						71.00	40												45						40					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00			35.00			35.00			35.00			35.00		35.00
S5921	415	0		29	10	S5921_415_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											758.00	33						520.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5953	001	0		29	10	S5953_001_0	5			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					12.00	24.00	36.00					12.00	24.00	30.00																15.00				12.00			0.50	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5953	001	0		29	10	S5953_001_0	5			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					17.00	34.00	51.00					17.00	34.00	42.50																20.00				17.00			0.67	0.57	0.57			0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																								
S5953	001	0		29	10	S5953_001_0	5			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											45.27	15	15	15				45.82	15	15	15				15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-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	5			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											53.63	50	50	50				51.79	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	70.00	105.00				35.00		35.00
S5953	001	0		29	10	S5953_001_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
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	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	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	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										5.00	10.00	15.00				5.00	10.00	15.00	2.50	5.00	7.50	5.00		5.00
S5993	001	0		29	10	S5993_001_0	8			Preferred Brand	2	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				42.05	20	20	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
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				45.64	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				325.93	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	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		0.00				0.00	0.00	0.00	Preferred Generic, 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	5			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	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	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	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				87.94	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	5			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				508.82	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										35.00												35.00		35.00
